Early versus delayed laparoscopic cholecystectomy in uncomplicated biliary colic: An observational study

Objective:Biliary colic is a condition treated with laparoscopic cholecystectomy.However,the outcomes of surgery depend on early or delayed time points.Few research findings reported no benefits of early over delayed,on contra,other reported benefits.This study aims to compare the benefits associated with early and delayed laparoscopic cholecystectomy among uncomplicated biliary colic patients.Methods:This observational study included patients with right upper abdominal pain and abdominal ultrasound showing cholelithiasis.Patients who were admitted at the first and second visits(within 6 weeks of the first visit)were assigned to the early and delayed groups,respectively.All participants were followed up for one-week postsurgery.The diagnosis of the patient,postoperative hospital stay,duration of surgery and complications were noted and compared primarily.Results:A total of 80 patients were included,40 each in the early group and delayed group.The patients in the two groups had comparable mean ages(40.55±13.12 y vs.40.45±12.06 y,p=0.972).The early group had more female patients(72.5%vs.45.0%,p=0.012).The duration of hospital stay(2.18±0.38 d vs.2.68±1.04 d,p=0.009)and duration of surgery(61.63±3.64 min vs.71.13±16.19 min,p=0.001)were found to be significantly different between the early and delayed groups.Only 1(2.5%)patient in both groups was converted to open cholecystectomy.Recurrent biliary colic requiring hospital admission was seen in 1(2.5%)patient and 6(15.0%)patients,acute cholecystitis in 2(5.0%)and 6(15.0%),biliary pancreatitis in 1(2.5%)and 2(5.0%),and obstructive jaundice in 1(2.5%)and 1(2.5%)in the early and delayed groups,respectively,with insignificant differences(p>0.05).Conclusion:Early laparoscopic cholecystectomy decreases the operating time and duration of hospital stay.In terms of postoperative complications,our study did not find any significant difference between the groups.

Acquisition of naturally acquired antibody response to Plasmodium falciparum erythrocyte membrane protein 1-DBLα and differential regulation of IgG subclasses in severe and uncomplicated malaria

Objectives: To explore whether individuals infected with Plasmodium falciparum(P. falciparum) develop antibodies directed against Pf EMP1-DBLa, and to assess their IgG subclass distribution in severe and uncomplicated malaria.Methods: The anti-PfDBLα IgG and their IgG subclass distributions in plasma of severe(SM) and uncomplicated malaria(UCM) were assessed by enzyme-linked immunoabsorbent assay. The antibody profiles to P. falciparum blood stage antigens were evaluated. CD36 binding ability was determined by static receptor-binding assays.Rosette formation was performed by staining with acridine orange.Results: Significantly higher number of UCM(86.48%) than SM(57.78%) plasma contained total acquisition of specific IgG to P. falciparum antigens(P = 0.000). Similar manners were seen in response to P. falciparum DBLa with significant difference(UCM,59.46% vs SM, 40.00%; P = 0.014). Anti-PfDBLα-IgG1 and-IgG3 were the predominant subclasses. Similar percentage of UCM(31.82%) and SM(33.33%) plasma contained only IgG1, while 13.64% of UCM and 27.78% of SM plasma contained only IgG3. AntiPfDBLα-IgG1 coexpressed with more than one subclass was noted(UCM, 27.27%; SM,16.67%). Obviously, IgG1 coexpressed with IgG3(9.09%) was observed in only UCM plasma. IgG1 was coexpressed with IgG2 in UCM(9.09%) and SM(11.11%) plasma,while IgG1 was coexpressed with IgG4 only in UCM plasma(4.55%). IgG subclasses to P. falciparum antigens were distributed in a similar manner. Only the levels of IgG1, but not IgG3 were significantly higher in UCM than in SM.Conclusions: These data suggest that individuals infected with P. falciparum can develop the anti-Pf EMP1 antibodies with the major contribution of specific IgG subclasses. The balance and the levels of anti-PfDBLα IgG subclasses play a crucial role in antibody mediated protection against severe malaria.

Pattern of Uncomplicated Malaria Treatment and Antimalarial Prescription Practices among Health Workers in the Littoral Region of Cameroon: An Assessment of Ten Years Post-Malaria Treatment Policy Change

Following highly prevalent Plasmodium resistant strains to antimalarial monotherapies in malaria endemic countries, uncomplicated malaria treatment policy changed to artemisinine-based combination therapies (ACTs). After adoption of this new treatment policy in a country, sufficient care is needed to be taken to prevent occurrence of resistance to the latest drugs. As Cameroon shifted to ACT in 2004, this study aimed to assess knowledge and practices of health workers in government health facilities of the Littoral region regarding mild malaria management in health facilities as well as according to prescription qualities of ACTs in leaflets received in pharmacies. A total of 66 physicians and 16 nurses were questioned in 10 health facilities and 503 medical leaflets with ACTs prescriptions were viewed in 17 pharmacies. All medical workers questioned correctly were defined mild malaria and were aware of the antimalarial policy change in Cameroon. Overall ACTs prescription for mild malaria management in children and adult patients was 72.2% and 87.8% respectively. An important proportion of health workers prescribed antimalarial monotherapies and non recommended antimalarial for uncomplicated malaria treatment. 31.7% of participants did not systematically recommend laboratory diagnostic test before antimalarial prescription. Of leaflets viewed in pharmacies, ACTs were prescribed by physicians, nurses and laboratory technicians. Age was the only criteria for ACTs prescription. Appropriate ACTs quality prescription ranged between 81.2% and 94.4%. Of the ACTs prescribed, blisters had the highest (92.9%) appropriate quality prescription and solutions the lowest (83.3%). According to qualification of prescribers, physicians had the highest score (93.1%) of appropriate quality prescription and laboratory technicians the lowest score (28.1%). For all ACTs containing medical leaflets, concomitant medications were recorded namely antipyretic (73.9%), antibiotic (21.9%), non steroid anti-inflammatory (19.9%) or vitamins (18.1%). Data gathered indicated that although health workers were aware of uncomplicated malaria treatment policy change in Cameroon, mild malaria mismanagement was prevailing in health facilities of the Littoral region and ACTs quality prescription in medical leaflets was not optimal. Therefore, awareness is still needed among prescribers in order to prevent or at least slow the occurrence of Plasmodium resistant strains to ACTs in Cameroon.

Plasma glutathione and oxidized glutathione level, glutathione/oxidized glutathione ratio, and albumin concentration in complicated and uncomplicated falciparum malaria

Objective: To compare the level of glutathione(GSH) and oxidized glutathione(GSSG),the ratio of GSH/GSSG and the concentration of albumin in plasma of patients with complicated and un-complicated falciparum malaria.Methods: This research was a cross sectional study using comparison analysis with the plasma GSH and GSSG, the ratio of plasma GSH/GSSG and the concentration of plasma albumin as variables. The complicated malaria patients were obtained from Dr. Saiful Anwar Hospital Malang, whereas uncomplicated malaria patients were obtained from the Regency of Pleihari South Kalimantan. Plasma GSH and GSSG levels were determined by the spectrophotometer at the wave length of 412 nm, whereas the concentration of albumin was determined by bromocresol green method in the p H of 4.1.Results: There were no significant differences between the level of plasma GSH and GSSG in complicated and uncomplicated malaria patients, as well as the ratio of plasma GSH/GSSG in the two groups(P = 0.373; P = 0.538; and P = 0.615, respectively, independent ttest). In contrast, the plasma albumin concentration in complicated malaria patients were significantly higher than uncomplicated malaria patients(P = 0.000, Mann Whitney U test).Conclusions: It can be concluded that the average of plasma GSH and GSSG level, also plasma GSH/GSSG ratio in complicated malaria are not different from uncomplicated malaria. Although plasma concentration of albumin in both groups is below the normal range,there is an increase in complicated malaria that might be as compensation of oxidative stress.

A Comparative Study of Dihydroartemisin in Compounds in Treatment of Uncomplicated Falciparum Malaria in Kampong of Cambodia

Objective: To compare the safety and efficacy of two compounds of dihydroartemisinin(DHA) -Artekin and Artekin (T) in the treatment of uncomplicated falciparum malaria. Methods:The regimen of 8-tablet for 2 days of Artekin and Artekin (T) were applied to 100 patients with uncomplicated falciparum malaria, who were randomly divided into two groups. Each group contained 50 cases. The cure rate, the mean parasites clearance time, the mean fever clearance and side-effects were observed to assess the safety and efficacy of the compounds used. Results: The mean parasites clearance time was 31. 7±9.0 hours in the Artekin group and 32. 8±8. 8 hours in Artekin (T) group respectively; the mean fever clearance time was 12. 7±7. 2 hours in Artekin group and 16. 5±7. 9 hours in Artekin (T) group; there were no recrudescence case in both groups within the 28 days of follow-up, the cure rates in Artekin group and Artekin (T) groups were 100%. It indicated that the tolerability of both compounds were very good, the side-effects such as nausea, abdominal pain were mild and self-limited. Conclusion: The study preliminarily indicated that the DHA and PQ compounds were of high efficacy, rapid acting and low toxici-ty. Artekin is very promising as a cheap, simple, effective treatment for multi-resistance malaria in Cambodia.

Revisiting the Evaluation of the Effectiveness of Artemether-Lumefantrine Combination in the Treatment of Uncomplicated Malaria in Elele, a Malaria Endemic Area in Rivers State Nigeria

Background: The World Health Organization adopted Artenisinin based combination therapy (ACT) for the treatment of uncomplicated malaria in endemic regions. The efficacy of ACT in malaria treatment must have prompted this choice. There’s need to protect the ACT from plasmodial resistance. Hence, clinical scaling up of ACT program is needed. This entails continued assessment, monitoring and evaluation of the effectiveness of component drugs in endemic areas. Purpose: This study revisited the evaluation of the effectiveness of artemether-lumefantrine combination (ALC) in the treatment of uncomplicated malaria in Elele, Nigeria. Method: The study was conducted in Elele, a malaria endemic area in Rivers State, Nigeria. This was a facility based descriptive, cross sectional study at Madonna University Teaching Hospital (MUTH) Elele using simple sampling technique. Qualitative and quantitative data were collected. 100 patients who consented to the study were recruited in the outpatient clinic using semi structured questionnaires as part of study instrument. Inclusion criteria were having a body temperature of ≥37.5&deg;C, symptoms of malaria, positive parasitemia, non ingestion of antimalarial in the past 2 weeks, etc. MUTH ethics committee gave ethical clearance. Patient recruitment following consent commenced with their symptoms and signs recorded at presentation while disappearance of the same was determined following drug ingestion on days 2/4/6/8/10 and 14. The data gotten was analyzed by tallying the responses to get the frequencies using SPSS 16.0 version and Microsoft excel tools. The student t-test was used to calculate the P-value, values < 0.05 was considered statistically significant. Results: Most of the patients knew mosquitoes as the mode of malaria transmission (70%). The ACT is known and used by these patients: artesunate/amodiaquine: 41 (41%);artesunate/lumefantrine: 40 (40%);artesunate/sulphadoxine-pyrimethamine: 38(38%);artesunate/mefloquine: 20 (20%). Fever was the predominant presenting symptom, 92% followed by body weakness (90%);headache (85%);malaise (80%);loss of appetite (80%);nausea (72%);vomiting (70%);abdominal pains (50%). Others were: pallor (30%);hepatomegally (20%);splenomegally (20%);chills (20%);rigor (20%). By day 10 of therapy, fever, vomiting and abdominal pains had disappeared in all patients, some patients still had mild: body weakness 40%;headache 2%;malaise 24%;loss of appetite 20% and nausea 10%. Day 14 recorded no symptoms in all patients. There was effective clinical response (ECR) by day 14. Conclusion: This study hereby reaffirms the efficacy and effectiveness of Artemether-lumefantrine Combination in the treatment of uncomplicated malaria in Elele, Nigeria. The need to fill the existing knowledge gap of monitoring and evaluation of ACT in rural endemic areas has been done by this study.

Treatment of Uncomplicated Malaria among Under-Five Children: A Systematic Review

Most uncomplicated malaria dominated countries have embraced the recommended first-line treatment of uncomplicated malaria. Artemisinin-based combination therapies such as Artemether-Lumefantrine, Artesunate + Amodiaquine and Dihydroartemisinin-Piperaquine have shown to be effective with Artemether-Lumefantrine and considered the most effective and approved by WHO. The study collected and reviewed recent randomized controlled trials for the treatment of uncomplicated malaria under five children. Eligibility criteria for the selected studies were based on the use of tools such as PICO (T) and data extraction tools such as REPOSE guidelines, PRISMA statement and eligibility criteria. This study includes only RCTs on the treatment of uncomplicated malaria under 5 s. Data was analyzed through comparative-narrative analysis. This study found 8 studies. Selected studies had a total of 10,682 participants within the age range of 0 - 59 months with the diagnosis of uncomplicated malaria and an MCP range of 2000 - 200,000 treated with different antimalarial drugs. Artesunate + Amodiaquine and Dihydroartemisinin-Piperaquine and Artemether-Lumefantrine drugs were found to be consistent in the treatment of uncomplicated malaria under 5 s within three days. Findings show that Artemether-Lumefantrine, Artesunate + Amodiaquine and Dihydroartemisinin-Piperaquine were the best drugs of choice due to their fast rate in fever reduction and parasite clearance. The efficacy of Artesunate + Amodiaquine and Dihydroartemisinin-Piperaquine is comparable to Dihydroartemisinin-Piperaquine. The study concludes that Artesunate + Amodiaquine and Dihydroartemisinin-Piperaquine can also be drugs of choice along with the well-known and utilized Artemether-Lumefantrine combination because of the fever reduction and parasite clearance within the first three days duration.

Smoking history increases the risk of long-term mortality after thoracic endovascular aortic repair in patients with an uncomplicated type B dissection

Background:The preferred treatment for uncomplicated type B dissection(thoracic endovascular aortic repair[TEVAR]or medical)is still under debate.Since 2001,our center has performed TEVAR for uncomplicated type B dissection.Based on our data,5-and 10-year survival rates among patients with uncomplicated type B dissection after TEVAR were 96.5%and 83.0%,respectively.We,therefore,believe that TEVAR is preferable for uncomplicated type B dissections.This study analyzed the impact of a pre-operative smoking history on long-term survival after TEVAR in patients with uncomplicated type B dissections.Methods:From May 2001 to December 2013,data from 751 patients with type B dissections were collected and analyzed.Patients were divided into two groups(337 smoking patients and 414 non-smoking patients).The Kaplan-Meier method and log-rank test were used to compare survival curves of the two groups.Multivariable analyses using the Cox proportional hazards model were used to estimate the effects of smoking on survival rates.Results:The 5-and 10-year survival rates of non-smokers were 97.6%(95%confidence interval[CI],96.0%-99.2%)and 87.0%(95%CI,81.6%-92.7%),respectively,and 94.9%(95%CI,92.2%-97.7%)and 73.8%(95%CI,62.3%-87.5%)for smokers,respectively(Log-rank test,P=0.006).Multivariable analyses showed that smoking increased the risk of death during follow-up,2.1-fold when compared to non-smokers(P=0.039).Conclusion:A pre-operative smoking history increases long-term mortality rates after TEVAR in patients with uncomplicated type B dissections.

Discriminatory capacity of serum interleukin-6 between complicated and uncomplicated acute appendicitis in children:a prospective validation study

Background Serum interleukin-6(IL-6)has a moderate diagnostic performance in pediatric acute appendicitis(PAA).The evidence regarding its capacity to discern between complicated and uncomplicated PAA is scarce.Methods We designed a prospective observational study to validate serum IL-6 as a marker for diagnostic classification between complicated and uncomplicated PAA.This study included 205 patients divided into three groups:(1)patients who underwent major outpatient surgery(n=57);(2)patients with non-surgical abdominal pain(NSAP)in whom the diagnosis of PAA was excluded(n=53),and(3)patients with a confirmed diagnosis of PAA(n=95).The PAA patients were further classified as uncomplicated or complicated PAA.IL-6 concentration was determined in all patients at diagnosis.Comparative statistical analysis was performed using the Mann-Whitney U test,the Fisher exact test and the Kruskall Wallis test.The area under the receiver operating characteristic curves(AUC)were calculated.Results Median(interquartile range,IQR)serum IL-6 values were 2 pg/mL(2.0–3.4)in group 1,3.9 pg/mL(2.4–11.9)in group 2,and 23.9 pg/mL(11.1–61.0)in group 3(P<0.001).Among the participants in group 3,those with uncomplicated PAA had median(IQR)serum IL-6 values of 17.2 pg/mL(8.5–36.8),and those with complicated PAA had 60.25 pg/mL(27.1–169)serum IL-6(P<0.001).At the cut-off point of 19.55 pg/mL,the AUC for the discrimination between patients in group 2 vs.3 was 0.83[95%confidence interval(CI)0.76–0.90],with a sensitivity of 61.3%and a specificity of 86.8.The AUC for the discrimination between patients with uncomplicated and complicated PAA was 0.77(95%CI 0.68–0.86)and the cut-off point was 25.90 pg/mL,with a sensitivity and specificity of 84.6%and 65.6%,respectively.Conclusions Serum IL-6 has a good performance in discerning between complicated and uncomplicated PAA.A score including clinical and radiological variables may increase the diagnostic performance of this molecule.

Efficacy of Nonsteroidal Anti-inflammatory Drugs for Treatment of Uncomplicated Lower Urinary Tract Infections in Women:A Meta-analysis

Urinary tract infections(UTIs)are among the most frequent causes for antibiotic prescription and;therefore,alternative treatment options for UTIs can potentially reduce antibiotic usage and development of resistance.To evaluate the efficacy of nonsteroidal antiinflammatory drugs(NSAIDS)for the treatment of uncomplicated lower UTIs in women,this study implemented a meta-analytic approach to evaluate the results of available randomized clinical studies from online databases.A total of four trials involving 1144 patients with uncomplicated lower UTIs were included in the final evaluation.Results showed that symptom resolution at Day 3-4 in the NSAIDs group was significantly lower than that in the antibiotics group[pooled odds ratio(OR)=0.41,95%confidence interval(CI):0.23-0.74,P<0.05].However,there was no significant difference between the NSAIDs and antibiotics groups in symptom resolution at Day 7(pooled OR=0.43,95%CI:0.17-1.06,P=0.07),secondary antibiotic treatment rate at Day 28-30(pooled OR=1.15,95%CI:0.16-7.98,P=0.89)and adverse events rate(pooled OR=1.09,95%CI:0.61-1.96,P=0.77).Therefore,this metaanalysis suggests that,although inferior to antibiotics in fast symptom resolution,symptomatic treatment with NSAIDs can be considered as an alternative treatment option for uncomplicated lower UTIs in women.However,given the low number of randomized controlled trials that met inclusion criteria in this meta-analysis,efficacy of NSAIDs for treatment of uncomplicated lower UTIs should be further evaluated in more comprehensive clinical studies.

The Impact of the Morphologic Characteristics of Type B Aortic Dissection in the Acute Phase on the Aortic Enlargement in the Late Stage

Objectives: According to the International Registry of Acute Aortic Dissection, >70% of patients with type-B aortic dissection (AD) have delayed aortic growth. The objective of this study was to investigate the morphologic characteristics of aortic enlargement in type-B AD. Methods: A total of 120 patients with uncomplicated acute type-B aortic dissection (uATBAD) were divided into 4 groups according to the presence of a patent or thrombosed false lumen (FL) with or without aortic enlargement. In all groups, the area of the true lumen (TL) and the FL were measured on axial computed tomography images. Results: A total of 120 uATBAD patients were evaluated: patent FL with (PE, N = 28, 23%) or without aortic enlargement (PU, N = 17, 14%) and thrombosed FL with (TE, N = 34, 28%) or without enlargement (TU, N = 41, 34%). The initial aortic diameter was not significantly different among the 4 groups (PE vs. PU = 39 ± 8 vs. 37 ± 10 (p = 0.354);TE vs. TU = 38 ± 6 vs. 37 ± 6 (p = 0.391)). The area of the FL tended to be larger in the PE group. In contrast, the area of the TL was significantly larger in the TE group. Late outcomes of uATBAD treated with optimal medical treatment were acceptable. Conclusions: In patients with uATBAD and a thrombosed FL, the patients with aortic enlargement tended to be increased TL size. In contrast, in patients with a patent FL, the patients with aortic enlargement tended to be increased FL size.

How Not to Miss a Case of Malaria in Emergency Department in Malaria Non-Endemic Areas? Practical Approach &Experiences in Hong Kong

Human malaria is a life-threatening mosquito-borne protozoan parasitic infection in human involving female anopheline mosquitoes as vector for transmission. It is caused by Plasmodium species, most commonly, P. vivax, P. ovale, P. malariae and P. falciparum, and rarely P. knowlesi. Malaria remains a significant global health issue and is a medical emergency. It is also an important cause of morbidity and mortality in endemic areas, particularly in at-risk groups. In Hong Kong, where malaria is non-endemic, more than 20 cases of malaria per year have been notified in recent years. We still have chances encountering patients with malaria presented to public or private emergency departments. High index of clinical suspicious is utmost important for not missing a case of malaria. A practical approach for prompt identification of patients with severe malaria is essential, followed by appropriate initiation of appropriate effective antimalarial treatment within 24 to 48 hours of symptoms onset after blood taken for thick and thin smears for diagnosis. Vigilance with increased awareness of not falling into common diagnostic traps has to be alerted. The risk of missing any case of malaria presenting to emergency department could be largely minimized.

“One-day,one-stay,and one-step”lessons from the Danish guidelines for the treatment of gallstone disease

Introduction.Gallstone disease is prevalent worldwide,and the incidence in Europe increased over the last decades.The median prevalence ranges from 5.9%to 21.9%,with the highest rates seen in Norway(21.9%)and the eastern part of Germany(19.7%)and the lowest rates in Italy(<7%)(1).In The Netherlands,over 100,000 patients are diagnosed with symptomatic gallstones annually,costing around 250 million euros,ranking gallstones disease in the top 10 of the most prevalent and costly gastrointestinal disorders(2).