Using SNP addresses for Salmonella Typhimurium DT104 in routine veterinary outbreak detection.

SNP addresses are a pathogen typing method based on whole-genome sequences (WGSs), assigning groups at seven different levels of genetic similarity. Public health surveillance uses it for several gastro-intestinal infections; this work trialled its use in veterinary surveillance for salmonella outbreak detection. Comparisons were made between temporal and spatio-temporal cluster detection models that either defined cases by their SNP address or by phage type, using historical data sets. Clusters of SNP incidents were effectively detected by both methods, but spatio-temporal models consistently detected these clusters earlier than the corresponding temporal models. Unlike phage type, SNP addresses appeared spatially and temporally limited, which facilitated the differentiation of novel, stable, or expanding clusters in spatio-temporal models. Furthermore, these models flagged spatio-temporal clusters containing only two to three cases at first detection, compared with a median of seven cases in phage-type models. The large number of SNP addresses will require automated methods to implement these detection models routinely. Further work is required to explore how temporal changes and different host species may impact the sensitivity and specificity of cluster detection. In conclusion, given validation with more sequencing data, SNP addresses are likely to be a valuable addition to early warning systems in veterinary surveillance.

Investigation of prevalence and risk factors for Campylobacter in broiler flocks at slaughter: results from a UK survey.

During 2007-2009 a UK-wide, 3-year stratified randomized survey of UK chicken broiler flocks was conducted to estimate the prevalence of Campylobacter-infected batches of birds at slaughter. Thirty-seven abattoirs, processing 88·3% of the total UK slaughter throughput, were recruited at the beginning of the survey. Of the 1174 slaughter batches sampled, 79·2% were found to be colonized with Campylobacter, the majority of isolates being C. jejuni. Previous partial depopulation of the flock [odds ratio (OR) 5·21], slaughter in the summer months (categorized as June, July and August; OR 14·27) or autumn months (categorized as September, October and November; OR 1·70) increasing bird age (40-41 days, OR 3·18; 42-45 days, OR 3·56; ⩾46 days, OR 13·43) and higher recent mortality level in the flock (1·00-1·49% mortality, OR 1·57; ⩾1·49% mortality, OR 2·74) were all identified as significant risk factors for Campylobacter colonization of the birds at slaughter. Time in transit to the slaughterhouse of more than 2·5 h was identified as a protective factor (OR 0·52).

Application of variable number of tandem repeat analysis to track Salmonella enterica ssp. enterica serovar Typhimurium infection of pigs reared on three British farms through the production cycle to the abattoir.

AIMS: This study investigated the diversity and persistence of Salmonella strains through the pork finishing cycle, from the farm into the abattoir. METHODS AND RESULTS: Isolates from four batches of finishers, from farm to abattoir, were used. Salmonella Typhimurium isolates were subjected to molecular typing using pulsed-field gel electrophoresis and variable number of tandem repeat analysis. The results demonstrated that infection was transferred from the farm to the abattoir. Within the abattoir, infection from individual pigs contaminated the exterior of the carcass and pigs exposed to Salmonella in the lairage were infected. CONCLUSIONS: Salmonella can be introduced at various points in the pig production and slaughter process. Carcass contamination may arise from infection on farm and exposure in the lairage and abattoir environment. Pigs could be contaminated by previous batches of pigs while in lairage or during the dressing process. Salmonella infection on farms is dynamic with multiple serovars present from different sources. SIGNIFICANCE AND IMPACT OF THE STUDY: Molecular typing methods facilitated the tracing of Salm. Typhimurium through the production cycle and differentiated some farm-acquired from abattoir-acquired strains. The findings emphasize the importance of integrated control strategies along the pork food chain.

Investigation of risk factors for Salmonella on fattening-turkey farms.

A cross-sectional study into risk factors for Salmonella was undertaken using data gathered from 252 fattening turkey flocks in the UK. The data was derived from the EU baseline survey conducted during 2006 and 2007, in addition to a voluntary questionnaire. Multivariate logistic regression models identified significant risk factors for Salmonella spp. and Salmonella Typhimurium. A decreased risk of Salmonella spp. infection was associated with a history of intestinal illness in the sampled flock (OR 0.17), the use of wood shavings as litter (OR 0.21), use of disinfectant in the cleaning process (OR 0.25), incineration of dead birds on farm (OR 0.29), seasonal production (OR 0.31), farm staff also working with cattle (OR 0.31), and the presence of pigs on neighbouring farms (OR 0.38). The risk of isolating Salmonella spp. varied according to the company from which the poults were sourced. A reduced risk of S. Typhimurium infection was associated with the use of wax blocks to control rodents (OR 0.09), using mains water (OR 0.19) and having a Salmonella test programme (OR 0.23). An increased risk of S. Typhimurium infection was associated with storage of items around the turkey house (OR 5.20), evidence of mice (OR 4.71) and a soil surface surrounding the turkey house (OR 2.70). This study therefore identifies a number of important practical measures which can be implemented by farmers and veterinarians within the turkey industry to assist in the control of salmonellosis at the farm level.

Survey of the prevalence of Salmonella on commercial broiler farms in the United Kingdom, 2005/06.

Between October 2005 and September 2006, all European Union member states were required to carry out standardised surveys of the prevalence of Salmonella in broiler flock holdings to establish baseline data from which to derive national targets for disease reduction. In the uk 382 holdings were sampled, 41 of which were positive for Salmonella, giving an estimated weighted prevalence of 10.7 per cent (95 per cent confidence interval [ci] 8.1 to 13.1 per cent). The serotype most frequently isolated was Salmonella Ohio, with a weighted prevalence of 2.2 per cent (95 per cent ci 1.2 to 3.7 per cent), followed by Salmonella Kedougou at 1.7 per cent (95 per cent ci 0.9 to 3.2 per cent). There were no isolates of Salmonella Enteritidis and only a single isolation of Salmonella Typhimurium (0.2 per cent, 95 per cent ci 0.0 to 1.6 per cent). Of the three other serotypes given top priority by the eu owing to their public health significance, Salmonella Virchow was isolated from one holding, but Salmonella Hadar and Salmonella Infantis were not detected on any of the holdings.

Risk-based surveillance for H5N1 avian influenza virus in wild birds in Great Britain.

Recent outbreaks of the H5N1 strain of avian influenza in Europe have highlighted the need for continuous surveillance and early detection to reduce the likelihood of a major outbreak in the commercial poultry industry. In Great Britain (gb), one possible route by which H5N1 could be introduced into domestic poultry is through migratory wild birds from Europe and Asia. Extensive monitoring data on the 24 wild bird species considered most likely to introduce the virus into GB, and analyses of local poultry populations, were used to develop a risk profile to identify the areas where H5N1 is most likely to enter and spread to commercial poultry. The results indicate that surveillance would be best focused on areas of Norfolk, Suffolk, Lancashire, Lincolnshire, south-west England and the Welsh borders, with areas of lower priority in Anglesey, south-west Wales, north-east Aberdeenshire and the Firth of Forth area of Scotland. These areas have significant poultry populations including a large number of free-range flocks, and a high abundance of the 24 wild bird species.

Survey of the prevalence of Salmonella species on commercial laying farms in the United Kingdom.

A survey of salmonella infection on 454 commercial layer flock holdings in the uk was carried out between October 2004 and September 2005. Fifty-four (11.7 per cent, 95 per cent confidence interval 9.3 to 14.0 per cent) were salmonella positive. The most common serovar identified was Salmonella Enteritidis at a prevalence of 5.8 per cent, and 70 per cent of these isolates were phage types 4, 6, 7 and 35. Salmonella Typhimurium was the second most prevalent serovar, found in 1.8 per cent of the farms. Of the three other serovars given top priority by the eu because of their public health significance, Salmonella Virchow and Salmonella Infantis were each isolated from one holding, but Salmonella Hadar was not isolated from any of the holdings. Analysis of antimicrobial resistance patterns revealed that over 76 per cent of the isolates were sensitive to all of the 16 drugs tested, and all the isolates were sensitive to ciprofloxacin, gentamicin, ceftazidime, apramycin, amikacin, amoxicillin/clavulanic acid, neomycin and cefotaxime.

Bovine bladder urothelial cell activation of carcinogens to metabolites mutagenic to Chinese hamster V79 cells and Salmonella typhimurium.

The ability of bovine bladder urothelial cells to activate genotoxic chemicals to mutagens was examined by cocultivating bladder cells with Chinese hamster V79 cells or Salmonella typhimurium as mutable targets. Activation of test chemicals to mutagenic intermediates by urothelial cells was detected by induction of 6-thioguanine resistance in V79 cells or by induction of histidine revertants in Salmonella. In the bladder cell-mediated V79 cell mutagenesis system, a significant increase in mutation frequency was induced by exposure to 7,12-dimethylbenz(a)anthracene and dimethylnitrosamine. The aromatic amines 2-aminofluorene, 2-acetylaminofluorene, and 4-aminobiphenyl were weakly mutagenic to V79 cells with bladder cell activation, while no mutagenic activity was detected with 1-naphthylamine, 2-naphthylamine, or benzidine. Because the mutagenic activity of the aromatic amines was low with V79 cells as the target, a bladder cell-mediated S. typhimurium system was developed for these chemicals. The aromatic amines 2-aminofluorene, 2-acetylaminofluorene, 4-aminobiphenyl and 2-naphthylamine were mutagenic to S. typhimurium TA98 and TA100 in the presence of bladder cells but not in their absence. Benzidine was mutagenic to TA98 but not to TA100. The putative noncarcinogen 1-naphthylamine was not mutagenic in the system. In contrast to the V79 data, 7,12-dimethylbenz(a)anthracene and dimethylnitrosamine were not mutagenic with either bacterial strain. Mutagenic responses were related to both the number of bladder cells used for activation and the concentration of test chemical in the Salmonella assay. The data demonstrate that bovine bladder urothelial cells can activate carcinogens from three chemical classes to mutagens and indicate the different sensitivities of V79 cells and S. typhimurium to genotoxic agents.

Immobilization of cellulase on a silica gel substrate modified using a 3-APTES self-assembled monolayer.

Cellulase was immobilized onto silica gel surfaces pretreated with (3-aminopropyl) triethoxy-silane (3-APTES), and glutaraldehyde (GA) was used as a cross-linker. A carboxymethyl cellulose sodium salt (CMC) solution was used for activity experiments. Protein assay was performed to determine the mass immobilized and compare with free enzyme. Cellulase was successfully demonstrated to be immobilized on the modified silica gel surface, and no detectable amount of enzyme was stripped off during the hydrolysis of the CMC solution. The specific activity of the immobilized cellulase is 7 ± 2 % compared to the similar amount of free cellulase. Significant activity over multiple reuses was observed. The seventh batch achieved 82 % activity of the initial batch, and the fifteenth batch retained 31 %. It was observed that the immobilized cellulase retained 48 % of its initial activity after 4 days, and 22 % even after 14 days.

Cooperativity of the concanavalin A inhibition of bovine milk fat globule membrane 5'-nucleotidase. Response to extraction of nucleotidase and of putative cytoplasmic surface coat components.

5'-Nucleotidase (5'-ribonucleotide phosphohydrolase, EC 3.1.3.5) of bovine milk fat globules can be solubilized by deoxycholate from either isolated globule membranes or washed cream. The solubilized and membrane-bound enzymes exhibit similar Km values and are inhibited by concanavalin A by an apparent noncompetitive process. The soluble enzyme shows positive cooperativity for the inhibition (Hill coefficient of 2) at 37 degrees C, but the membrane enzyme exhibits essentially no cooperation effect. At lower temperatures (5 or 20 degrees C) the cooperative effect in the inhibition of the soluble enzyme is lost. Colchicine and cytochalasin D failed to induce cooperativity of the concanavalin A inhibition of the membrane enzyme, but induction cooperativity occurred when membranes were extracted with glycine/EDTA/mercaptoethanol, releasing a major protein component with a polypeptide molecular weight of 155 000. We suggest that the interaction of this component with the membrane imposes restraints on the behavior of the nucleotidase which are reflected in the cooperativity of the inhibition of the enzyme by concanavalin A.

Activation of aromatic amines to mutagens by bovine bladder and liver cells.

A bovine bladder cell-mediated mutagenesis system using Chinese hamster V79 cells and Salmonella typhimurium as target organisms was developed to investigate the capacity of the bladder urothelium to activate chemical carcinogens. Bovine bladder epithelial cells can activate the aromatic amines AF and 4-ABP to intermediates which mutate V79 cells and S. typhimurium TA 98 and TA 100. DMBA was mutagenic to V79 cells but not detectably mutagenic to either Salmonella strain with bladder cell activation. The chemicals tested were not mutagenic to either target organism in the absence of bladder cells. In contrast to the response with DMBA, S. typhimurium was a more sensitive target for the arylamines than V79 cells. These data suggest the value of using multiple end points for assessing metabolic capability. The activation capability of intact bladder cells was compared to disrupted cells, and S-9 prepared from bladder cells used with and without cofactors. When intact cells or S-9 plus cofactors were used as the activation system a dose-dependent increase in revertants was observed for 4-ABP. A bovine liver cell-mediated bacterial mutagenesis system was also developed and the liver and bladder systems compared. For AF, bladder cells appear to be at least ten times more active per viable cell than hepatocytes in producing mutagenic intermediates, while 4-ABP is essentially not mutagenic in the hepatocyte-mediated system. A quantitative comparison of the relative importance of the liver and bladder to activate the chemicals is difficult to make but the data indicate the ability of the bladder epithelium to activate bladder carcinogens.

The effect of Roux-en-Y gastric bypass on prescription drug costs.

BACKGROUND: This study examines the effect of weight loss following laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity on prescription drug costs in patients over the age of 54. METHODS: 78 patients aged 55 to 75 who met the inclusion criteria were identified in a database of 1,060 morbidly obese patients undergoing LRYGBP between March 2001 and March 2003. All prescription drugs and dosages were recorded preoperatively and postoperatively at 6 months, 1 year, and yearly thereafter. Drug history was obtained from the patient and verified by records from referring physicians' offices. The cost of a 30-day supply of each drug was obtained from 3 retail sources and averaged. RESULTS: The average pre-LRYGBP cost of prescription drugs was $368.65 per month per patient. The average annualized cost at 6 months after LRYGBP was $119.10 per month (down 68%), at 1 year $118.67 (down 68%) and at 2 years $104.68 per month (down 72%). CONCLUSIONS: Weight loss resulting from LRYGBP significantly reduces obesity-related morbidities, resulting in a substantial reduction in medication needs in patients over the age of 54. The projected cost savings realized in the 78 patients in this study amounts to approximately $240,566.04 annually.

The behavioral implications of some old wives' tales.

A study was designed to gain information on the concerns, attitudes, beliefs, and knowledge that women have about reproduction to determine how these affect their health practices during pregnancy. A low-income multiethnic clinic population was studied in which the majority of the patients were in a high-risk category for pregnancy. They often failed to follow suggested regimens and/or engaged in negative health behaviors. Interviews with patients revealed that they too identified a number of risk factors in pregnancy, but that there was a disparity between their perceived risks and those of concern to the clinic staff. Many of the problems ascribed to patient noncompliance may be attributable to this differential perception of what constitutes a danger to pregnant women. In clinical settings where patients and professionals are divided by social class and cultural differences, it is suggested that physicians be aware of such beliefs so that patients may be reeducated to improve pregnancy outcomes.

The University of Maryland Medical System invests in its community's minorities.

As a private, non-state-owned teaching hospital adjacent to a predominately low income African American community in Baltimore, the University of Maryland Medical System (hereafter called the Medical System) in partnership with the state's medical school has historically provided excellent medical care to the community's residents regardless of their ability to pay. Nevertheless, executive leadership recognized that the Medical System needed to be even more socially and economically responsible to the minority community by investing more of the system's resources in that community. Doing so would improve the economic strength of the community, and this strength would help the Medical System to continue to thrive and expand its business in Baltimore City. Therefore, in the late 1980s, the Medical System created a program that focuses on greater inclusion of minorities particularly African Americans, in personnel, construction, purchasing, and community outreach. In the area of personnel, recruitment efforts have focused on increasing the representation of minorities, particularly African Americans, in management and residency positions. The result has been the creation of a more supportive environment for minority personnel throughout the organization as well as for minority patients and vendors who have dealings with the medical system. In the area of construction, minority development efforts have included the establishment of a flexible bid-award policy and a partnership with the minority business community. As a result, total construction dollars spent with minority-owned firms increased from $2 million to $18 million over seven years, and the portion of these dollars spent with African American-owned firms increased sixfold. In the area of purchased goods and services, more creative approaches to improving minority participation have been necessary. These have included partnering minority distributors with major suppliers and literally assisting in the creation of new minority firms capable of effectively responding to the competitive marketplace. As a result, purchasing dollars spent with minority-owned firms increased from $1.5 million to $3.2 million in four years, and the portion of these dollars spent with African American-owned firms nearly tripled. In community outreach, a comprehensive program has emerged that includes education, career development, disease prevention, and health promotion activities. The Medical System has encountered many barriers to success in these efforts but fortunately has overcome many of them. This article outlines the methods the system has used to achieve its minority development goals, with particular emphasis on the difficult area of purchasing.

Antipsychotic medications and the elderly: effects on cognition and implications for use.

Despite being frequently prescribed in the elderly, antipsychotic medications are commonly associated with adverse effects in this population, including sedative, orthostatic and extrapyramidal adverse effects. Growing evidence suggests that antipsychotics can also cause deleterious cognitive effects in some elderly patients. Preclinical and growing clinical evidence indicates that inhibitory effects on dopaminergic, cholinergic and histaminergic neurochemical systems may account for antipsychotic-associated cognitive impairment in the elderly. A review of published reports of the cognitive effects of antipsychotics in the elderly suggests that newer antipsychotic medications may possess a more favourable cognitive profile than that of traditional agents in this population. The cognitive effect that a specific antipsychotic will have in the elderly, however, is likely better predicted by considering the pharmacodynamic action of an individual agent in combination with the pathophysiology of the condition being treated. Agents with relatively weak dopamine inhibiting effects (e.g. clozapine and quetiapine), for example, would theoretically have a cognitive profile superior to that of agents with higher degrees of dopaminergic inhibition (all traditional agents, risperidone, olanzapine and ziprasidone) when used for conditions associated with diminished dopamine function (e.g. idiopathic Parkinson's disease). Drugs with weak anticholinergic effects (high-potency traditional agents, risperidone, quetiapine and ziprasidone) would theoretically be less likely to cause cognitive impairment than agents with high degrees of cholinergic receptor blocking actions (clozapine and olanzapine) when treating patients with impaired cholinergic function (e.g. Alzheimer's disease). Cholinergic agonist effects of clozapine and olanzapine may, however, mitigate potential adverse cognitive effects associated with the cholinergic blocking actions of these agents. Large, rigorous trials comparing the cognitive effects of antipsychotics with diverse pharmacodynamic actions are lacking in the elderly and are needed.

Assessment of reproductive knowledge in an inner-city clinic.

A number of studies have shown that misinformation and lack of information about the menstrual cycle contributes to unwanted fertility, particularly among black women. A short, self-administered questionnaire was developed and tested in an inner-city, prenatal clinic serving a primarily low-income undereducated, black clientele. Data were gathered concerning numbers of pregnancies and abortions, knowledge of the menstrual cycle, past contraceptive use, including dissatisfaction and discontinuance, and planned future use of contraception. Results showed that the majority of women had had at least one unwanted pregnancy. Their knowledge base about female reproductive function and their poor use of contraception contributed to these unwanted pregnancies. It is concluded that a few key questions can help identify the woman with special informational needs, enabling the health professional to gear educational efforts to the individual patient.

Comparison of insufflation vs retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine.

Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.

Comparison of insufflation vs. retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine.

Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs. 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.

Rehospitalization of older psychiatric inpatients: an investigation of predictors.

The purpose of this study was to identify a combination of variables that could predict rehospitalization among a sample of 150 geropsychiatric inpatients. Logistic regression analyses testing a modified model identified risk factors for geropsychiatric rehospitalization and correctly classified approximately 80% of inpatients who were rehospitalized for subsequent treatment. Patients' psychiatric diagnosis (mood or schizophrenic disorder), poor general psychiatric functioning, depressive and agitated behavior at discharge, little or no supervision in living arrangements following discharge, limited social support, change in the social support system preceding hospitalization, and maladaptive family functioning could significantly predict geropsychiatric rehospitalization. The strongest independent predictor was maladaptive family functioning.

Management of bile duct stones in 1572 patients undergoing laparoscopic cholecystectomy.

Evidence of bile duct stones (BDSs) was identified on routine cholangiogram in 136 (8.7%) of 1572 patients undergoing laparoscopic cholecystectomy from March 1989 through March 1997. Forty-two (30.9%) were unsuspected. All patients with evidence of BDSs underwent laparoscopic bile duct exploration (LBDE). Initially, a standard choledochotomy with T-tube drainage as in the open approach was used. Later, transcystic duct exploration was added to the algorithm. The algorithm evolved into an ongoing treatment protocol study that was initiated in March 1992. Through March 1997, 100 patients underwent LBDE based on the protocol. The study is divided into two groups. Group A comprises the total 136 patients undergoing LBDE, including those in the protocol study. A subgroup, Group B, comprises only the 100 patients in the protocol study. In Group A, LBDE was successful in 114 patients (83.8%). Stones were missed in seven patients and left behind for spontaneous passage or later retrieval in six patients. Eleven patients (8.1%) were converted to open. There were 13 major complications (9.6%), including the seven missed stones and two deaths. In Group B, LBDE was successful in 94 per cent. Stones were missed in one patient and intentionally left behind in four patients. One patient was converted to open. There were seven major complications (7%), including one of the missed stones and one death. Using the protocol algorithm and the techniques described, BDSs can be effectively managed laparoscopically at the time of cholecystectomy in approximately 94 per cent of cases.