One session laparoscopic management of Mirizzi syndrome: feasible and safe in specialist units

BACKGROUND:To evaluate the laparoscopic management of Mirizzi syndrome, seldom diagnosed preoperatively causing difficulty when performing cholecystectomy and increasing complication risks. METHODS:Analysis of a prospective single-surgeon database of 5700 laparoscopic cholecystectomies found 58 Mirizzi syndrome cases. They were managed with an intention to treat during the index admission according to protocol of single-session management of bile duct stones. RESULTS:38/58 patients were females (65.5%). The median age was 55 years. 53 cases were emergency admissions. 34 cases (58.6%) only had ultrasound scanning. Operative difficulty was Grade IV in 34 cases (58.6%) and Grade V in 20 (34.5%) (Nassar Scale). There were 33 Mirizzi Type IA, 7 Type IB, 16 Type II and one each of Type III and Type IV. Bile duct exploration was performed in 94.8% through choledochotomy/ transfistula in 58.6% or transcystic in 36.2%. Four cases required conversion to open. Postoperative morbidity occurred in 29%. Two 30-day mortalities occurred from pneumonia in two elderly patients who were late referrals. CONCLUSION:Although the utilization of the laparoscopic approach in managing bile duct stones is not currently widely practiced it was safer in this series than in reported series of open surgery in Mirizzi Syndrome. The optimal approach to Mirizzi Type II is via cholecystocholedochal fistula to explore the bile duct then drain with T-tube through the fistula. It is unnecessary to perform bilioenteric bypass in majority of cases, reducing the morbidity and mortality

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey

Accepted Article online 30 October 2014. The copyright line for this article was changed on 14 February, 2017 after original online publication.Aim: Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria. Method: A cross-sectional survey was conducted in a primary care setting in Sydney, Australia. A self-administered questionnaire was used to collect demographic information and diagnose FBDs (irritable bowel syndrome, constipation, functional bloating and functional diarrhoea) based on Rome III criteria. The severity of FI was determined using the Vaizey incontinence score. Associations with medical/surgical history and healthcare utilization were assessed. Results: Of 596 subjects approached, 396 (66.4%) agreed to participate. Overall, 33% had FBD and/or FI. Irritable bowel syndrome was present in 11.1% and these participants were more likely to report anxiety/depression (P 8). Participants with FI were more likely to have irritable bowel syndrome, urinary incontinence and previous anal surgery (P < 0.01). Conclusion: FBDs and FI are prevalent conditions amongst primary healthcare seekers and the needs of those affected appear to be complex given their coexisting symptoms and conditions. Currently, the majority do not reach colorectal services, although increased awareness by primary care providers could lead to sufferers being referred for specialist management.K.-S. Ng, N. Nassar, K. Hamd, A. Nagarajah and M. A. Gladma

New Exact Jacobi Elliptic Function Solutions for Nonlinear Equations Using F-expansion Method

In this work, Jacobi elliptic function solutions for integrable nonlinear equations using F-expansion method are represented. KdV and Boussinesq equations are considered and new results are obtained.Key Words: Jacobi elliptic functions; F-expansion method; Solitary waves; Periodic solution

Locked-In with COVID-19

© 2020 Elsevier Ltd Coronavirus Disease 2019 (COVID-19) can be associated with various neurological manifestations including acute strokes. Hyper acute diagnosis and treatment are key factors which decrease mortality and morbidity in stroke patients. The COVID-19 pandemic has introduced a great strain on the healthcare system, and as a result clinicians are facing several barriers in diagnosing and treating strokes. Delayed presentation of strokes is a problem as some in the general population defer the decision to seek immediate medical attention fearing contracting the virus. Also playing a role is the paucity of healthcare professionals available during a pandemic. Recent literature demonstrates the association of acute strokes in young patients with COVID-19. Lack of clear pathophysiology of the neurological manifestations from COVID-19 intensifies the problem. A thorough examination of the intensive care unit patient has always been a challenge owing to several factors including use of sedatives, sepsis, uremia, and encephalopathy secondary to medications. Locked-In Syndrome (LIS) secondary to stroke is much more challenging to diagnose as patients are unable to communicate or elicit any motor functions apart from certain ocular movements. We present the case of a 25 year old patient with no known history of coagulopathy, but had developed COVID-19 cytokine storm which culminated in LIS secondary to pontine strokes

Worldwide network for blood and marrow transplantation (WBMT) recommendations for establishing a hematopoietic stem cell transplantation program in countries with limited resources (Part II): Clinical, technical and socio-economic considerations

The development of hematopoietic stem cell transplantation (HSCT) programs can face significant challenges in most developing countries because such endeavors must compete with other government health care priorities, including the delivery of basic services. While this is may be a limiting factor, these countries should prioritize development of the needed expertise to offer state of the art treatments including transplantation, by providing financial, technological, legal, ethical and other needed support. This would prove beneficial in providing successful programs customized to the needs of their population, and potentially provide long-term cost-savings by circumventing the need for their citizens to seek care abroad. Costs of establishing HSCT program and the costs of the HSCT procedure itself can be substantial barriers in developing countries. Additionally, socioeconomic factors intrinsic to specific countries can influence access to HSCT, patient eligibility for HSCT and timely utilization of HSCT center capabilities. This report describes recommendations from the Worldwide Network for Blood and Marrow Transplantation (WBMT) for establishing HSCT programs with a specific focus on developing countries, and identifies challenges and opportunities for providing this specialized procedure in the resource constrained setting

Timing Driven Genetic Algorithm for Placement

In this paper we present a timing -driven placer for standard-cell IC design. The placement algorithm follows the genetic pradigm. At early generations, the search is biased towards solutions with superior timing characteristics. As the algorithm starts converging towards generations with acceptable delay properties, the objective is dynamically adjusted towards optimizing area and routability. Experiments with test circuits demonstrate delay performance improvement by upto 20%. Without any noticeable loss in solution quality, sizebale reduction in runtime is obtained when population size is allowed to decrease in a controlled manner whenever the search hits a plateau

Association of Inherited Thrombophilia with Recurrent Pregnancy Loss in Palestinian Women

Objective. This study aimed at analyzing the association between recurrent pregnancy loss (RPL) and factor V G1691A (FVL), prothrombin G20210 (FII); and MTHFR C677T (MTHFR) in Palestinian women. Method. We studied 329 Palestinian women with RPL and/or stillbirth (SB); and compared them to 402 healthy reproductive Palestinian women. Cases and controls were tested for the above mutations. Odds ratio (OR) at confidence interval (CI) of 95% was used as a measure of association between the mutations and RPL. Results. Our statistical analysis showed a slightly increased association, which was not significant between FVL and RPL (OR 1.32, 95% CI 0.90–1.94), and no association between FII (OR 0.84, 95% CI 0.38–1.92), MTHFR (OR 0.58, 95% CI 0.32–1.03), and RPL. Further analysis of RPL subgroups revealed an association between FVL and first-trimester loss (OR 1.33, 95% CI 0.892–1.989), and second-trimester loss (OR 1.13, 95% CI 0.480–2.426), both were not statistically significant. Furthermore, the only statistically significant association was between FVL and SB (OR 2.0, 95% CI 1.05–3.70). Conclusion. Our analysis had failed to find a significant association between FVL, FII, MTHFR; and RPL in either the first or second trimester. FVL was significantly associated with fetal loss if the loss was a stillbirth

Timing driven genetic placement

IN this paper we present a timing driven placer for standard cell IC design. The placement algorithm follows the genetic paradigm, with the objective of minimizing both area and path slacks. At early generations, the search is biased toward solutions with superior timing characteristics. As the algorithm starts converging towards generations with acceptable delay properties, the objective is dynamically adjusted toward optimizing area and routability. Experiments with benchmark test demonstrate delay performance improvement by up to 20%. It is also shown that sizeable reduction in runtime is obtained when population size is allowed to decrease in a controlled manner whenever the search his a plateau. This reduction in runtime is achieved without any noticeable loss in solution quality

Performance Driven Standard-cell Placement Using the Genetic Algorithm

Current placement systems attempt to optimize several objectives, namely area, connection lenght, and timing performance. In this paper we present a timing-driven placer for standard-cell IC design. The placement algorithm follows the genetic paradigm. Besides optimizing for area and wire length, the placer minimizes the propogation delays on a predicted set of critical paths. The paths are enumerated using a new approach based on the notion of criticality. Experiments with test circuits demonstrate delay performance improvement by upto 20