A risk score for conversion from laparoscopic to open cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy has become the standard operative procedure for cholelithiasis, but there are still some patients requiring conversion to open cholecystectomy mainly because of technical difficulty. Our aim was to develop a risk score for prediction of conversion from laparoscopic to open cholecystectomy. METHODS: Preoperative clinical, laboratory, and radiologic parameters of 1,000 patients who underwent laparoscopic cholecystectomy were analyzed for their effect on conversion rates. Six parameters (male sex, abdominal tenderness, previous upper abdominal operation, sonographically thickened gallbladder wall, age over 60 years, preoperative diagnosis of acute cholecystitis) were found to have significant effect in multivariate analysis. A constant and coefficients for these variables were calculated and formed the risk score. RESULTS: Overall 48 patients required conversion to open cholecystectomy (4.8%). These patients had significantly higher scores (mean 6.9 versus -7.2, P <0.001). Increasing scores resulted with significant increases in conversion rates and probabilities (P <0.001). Ideal cut-off point for this score was -3; conversion rate was 1.6% under -3, but 11.4% over this value (P <0.001). CONCLUSIONS: Conversion risk can be predicted easily by this score. Patients having high risk may be informed and scheduled appropriately. An experienced surgeon has to operate on these patients, and he or she has to make an early decision to convert in case of difficulty.     

A clinical forensic scientist in the burns unit: Necessity or not?: A prospective clinical study

Child abuse by burning is a common means of assault that may be difficult to prove. Even though well trained in burns management physicians on the burn team may not be sufficiently qualified to clarify the medicolegal aspects of the incident. In Turkey, physicians have a responsibility to notify the law offices of injury to children caused by any non-accidental mechanism including neglect. The consequences of false positive and/or false negative reports to the legal offices may be damaging for the care-takers and/or the children. In our study, 239 consecutively hospitalized children with burns were studied prospectively. A clinical forensic scientist and a physician of the burns team interpreted incidents separately so that neither had an idea about the other's diagnoses until the end of the study. There were found to be some differences in the interpretation of the incidents by the clinical forensic scientist and the burns team physician. These differences were described as discordant diagnoses. The physician accepted 99 (41.4%) of the incidents as an accident while only 66 (27.6%) of the victims were labelled as accidents by the forensic scientist. A multivariate analysis identified low socioeconomic status, aged between 3 and 6 years, and a family size of more than six as independent variables significantly associated with discordant diagnoses (p = 0.0388, 0.0001, 0.0203, respectively). As a conclusion, we suggest that to minimize the likelihood of a legally inaccurate diagnosis, a clinical forensic scientist seems to be necessary in the emergency department.     

Effects of a 5-lipoxygenase-activating protein inhibitor on biomarkers associated with risk of myocardial infarction: a randomized trial

Context  Myocardial infarction (MI) is the leading cause of death in the world. Variants in the 5-lipoxygenase–activating protein (FLAP) gene are associated with risk of MI. Objective  To determine the effect of an inhibitor of FLAP on levels of biomarkers associated with MI risk. Design, Setting, and Patients  A randomized, prospective, placebo-controlled, crossover trial of an inhibitor of FLAP (DG-031) in MI patients who carry at-risk variants in the FLAP gene or in the leukotriene A₄ hydrolase gene. Of 268 patients screened, 191 were carriers of at-risk variants in FLAP (87%) or leukotriene A₄ hydrolase (13%). Individuals were enrolled in April 2004 and were followed up by designated cardiologists from a university hospital in Iceland until September 2004. Interventions  Patients were first randomized to receive 250 mg/d of DG-031, 500 mg/d of DG-031, 750 mg/d of DG-031, or placebo. After a 2-week washout period, patients received DG-031 if they had received placebo first or placebo if they had received DG-031 first. Treatment periods lasted for 4 weeks. Main Outcome Measures  Changes in levels of biomarkers associated with risk of MI. Results  In response to 750 mg/d of DG-031, production of leukotriene B₄ was significantly reduced by 26% (95% confidence interval [CI], 10%-39%; P = .003) and myeloperoxidase was significantly reduced by 12% (95% CI, 2%-21%; P = .02). The higher 2 doses of DG-031 produced a nonsignificant reduction in C-reactive protein (16%; 95% CI, –2% to 31%; P = .07) at 2 weeks. However, there was a more pronounced reduction (25%; 95% CI, 5%-40%; P = .02) in C-reactive protein at the end of the washout period that persisted for another 4 weeks thereafter. The FLAP inhibitor DG-031 was well tolerated and was not associated with any serious adverse events. Conclusion  In patients with specific at-risk variants of 2 genes in the leukotriene pathway, DG-031 led to significant and dose-dependent suppression of biomarkers that are associated with increased risk of MI events.      

Intrabiliary rupture of a hepatic hydatid cyst: associated clinical factors and proper management.

HYPOTHESIS: The prediction of an intrabiliary rupture of a hepatic hydatid cyst using associated clinical factors is important for early diagnosis and proper management. DESIGN: Case series of patients with hepatic hydatid cysts treated between January 1, 1992, and January 1, 2000, in a single institution. SETTING: A tertiary care teaching hospital. PATIENTS: The clinical findings in 116 patients with a hepatic hydatid cyst were reviewed. Of the 116 patients, 24 (21%) had a cyst-biliary communication: 15 (13%) had an occult rupture, and 9 (8%) had a frank rupture. MAIN OUTCOME MEASURES: The following variables were analyzed as potential predictors of an intrabiliary rupture: age, sex, type and duration of symptoms, findings on physical examination, leukocyte count, liver function test results, serologic test results, suggestive ultrasonographic findings, ultrasonographic cyst features (type, diameter, number, and localization), and whether the cyst is primary or recurrent. RESULTS: The independent clinical factors for the presence of an occult rupture were a history of nausea and vomiting (P = .004), alkaline phosphatase level greater than 144 U/L (P = .004), total bilirubin level greater than 0.8 mg/dL (>13.5 micromol/L) (P< .001), and cyst diameter greater than 14.5 cm (P< .001) in multivariate analysis. Multivariate analysis also showed that history of jaundice (P< .001), jaundice found on physical examination (P = .05), cyst diameter greater than 10.5 cm (P = .009), a type IV cyst (P< .001), and suggestive ultrasonographic findings (P< .001) were the independent clinical predictors for the presence of a frank intrabiliary rupture. Patients with cyst-biliary communications had increased morbidity rates (13 [54%] of 24 patients vs 13 [14%] of 92 patients; P< .001) and longer mean postoperative hospital stays (13.7 vs 9.4 days; P = .03) compared with others. CONCLUSION: Clinical predictors should be considered for early diagnosis and proper management of intrabiliary ruptures in patients with hepatic hydatid cysts.     

Mineralization in a Critical Size Bone-Gap in Sheep Tibia Improved by a Chitosan-Calcium Phosphate-Based Composite as Compared to Predicate Device

Deacetylated chitin derivatives have been widely studied for tissue engineering purposes. This study aimed to compare the efficacy of an injectable product containing a 50% deacetylated chitin derivative (BoneReg-Inject™) and an existing product (chronOS Inject^®) serving as a predicate device. A sheep model with a critical size drill hole in the tibial plateau was used. Holes of 8 mm diameter and 30 mm length were drilled bilaterally into the proximal area of the tibia and BoneReg-Inject™ or chronOS Inject^® were injected into the right leg holes. Comparison of resorption and bone formation in vivo was made by X-ray micro-CT and histological evaluation after a live phase of 12 weeks. Long-term effects of BoneReg-Inject™ were studied using a 13-month live period. Significant differences were observed in (1) amount of new bone within implant (p < 0.001), higher in BoneReg-Inject^TM, (2) signs of cartilage tissue (p = 0.003), more pronounced in BoneReg-Inject^TM, and (3) signs of fibrous tissue (p < 0.001), less pronounced in BoneReg-Inject^TM. Mineral content at 13 months postoperative was significantly higher than at 12 weeks (p < 0.001 and p < 0.05, for implant core and rim, respectively). The data demonstrate the potential of deacetylated chitin derivatives to stimulate bone formation.     

Anomaly-Based Intrusion Detection Using Extreme Learning Machine and Aggregation of Network Traffic Statistics in Probability Space

Recently, with the increased use of network communication, the risk of compromising the information has grown immensely. Intrusions have become more sophisticated and few methods can achieve efficient results while the network behavior constantly changes. This paper proposes an intrusion detection system based on modeling distributions of network statistics and Extreme Learning Machine (ELM) to achieve high detection rates of intrusions. The proposed model aggregates the network traffic at the IP subnetwork level and the distribution of statistics are collected for the most frequent IPv4 addresses encountered as destination. The obtained probability distributions are learned by ELM. This model is evaluated on the ISCX-IDS 2012 dataset, which is collected using a real-time testbed. The model is compared against leading approaches using the same dataset. Experimental results show that the presented method achieves an average detection rate of 91% and a misclassification rate of 9%. The experimental results show that our methods significantly improve the performance of the simple ELM despite a trade-off between performance and time complexity. Furthermore, our methods achieve good performance in comparison with the other few state-of-the-art approaches evaluated on the ISCX-IDS 2012 dataset.     

Effect of short-acting inhaler beta2-agonists on serum cardiac troponin in wheezy infant.

Cardiac troponin (cTn) is highly specific for myocardial injury. However, effect of beta2-agonist therapy on cTn in wheezy infants is unknown. We aimed to assess serum troponin in children with wheezy infant treated by short-acting inhaler beta2-agonists. Twenty-four children, under 5 years old, with the diagnosis of wheezy infant with acute exacerbation were enrolled in the study. Subjects were treated three times by a standard dose of nebulized salbutamol (0.15 mg/kg per dose; maximum, 3 mg; Ventolin Nebules Ampule) therapy. The heart rate, respiratory rate, cTnI, creatine kinase (CK), CK-MB levels, and electrocardiogram were measured in wheezy infant before and after 60-minute nebulized salbutamol. In the control group the heart rate, respiratory rate, cardiac troponin I (cTnI), CK, CK-MB levels, and electrocardiogram were recorded at admission. For Seventeen boys (70.8%) and seven girls (29.2%) with wheezy infant, the mean age of the patients was 21.4 +/- 18.13 months and for control groups the mean age was 17.28 +/- 16.09 months (p = 0.419). There was no significant difference in serum troponin in patients before treatment, after treatment period, and in controls (mean +/- SD, 0.049 +/- 0.03, 0.043 +/- 0.048, and 0.044 +/- 0.034, respectively; p = 0.14, p = 0.72, and p = 0.35, respectively). Short-acting inhaler 32-agonists do not influence circulating troponin levels in wheezy infant with acute attack.