Ann R Coll Surg Engl 2007; 89: 238-241 238Adenocarcinoma of the gall bladder is a rare but aggressive gastrointestinal malignancy. It carries a dismal prognosis, with a reported overall 5-year survival rate not exceeding 5%.1 According to a large multicentre survey commissioned by the French Surgical Association, the overall median survival is just 3 months, 2 the main reason being late presentation. It mainly affects patients in their 7th and 8th decade and is about 5 times more common in females. It is estimated that in 85% of cases it is associated with gallstones 3 but the only recognised pre-malignant condition is a 'porcelain gall bladder'. In the vast majority of patients who are diagnosed with gall bladder carcinoma, the first suspicion of malignancy arises during operation and is confirmed on histological examination of the specimen. Despite advances in radiological imaging, accurate preoperative diagnosis is the exception rather than the rule. At present, all specimens, regardless of their macroscopic appearance, are being sent for histological examination. It seems questionable whether the result of the histopathological examination of each gall bladder would alter management when it provides no advantage to the surgeon, patient or pathologist.The aim of the study was to assess the necessity of routine histological examination of the gall bladder following simple cholecystectomy and its impact on the further management of the patients. Patients and MethodsWe analysed, retrospectively, the electronic database of histological reports of all gall bladder specimens after cholecystectomy in the last 5 years. In all cases of confirmed malignancy, we retrieved and reviewed, from patients notes and, when missing, from the hospital electronic database, results of pre-operative investigations such as: liver function tests, ultrasound scans or computed tomography Gall bladder carcinoma is a rare malignancy that carries a very poor prognosis. Laparoscopic cholecystectomy (LC) is established as the gold-standard treatment for symptomatic gall stones. The aim of the study was to assess the incidence of gall bladder carcinoma and the possibility of reducing the routine histological examination of gall bladder specimens.

Angiotensin-(1-7) [Ang-(1-7)] reportedly potentiates hypotensive responses to bradykinin. We studied whether increases in circulating bradykinin would alter responses to Ang-(1-7). In rats anesthetized with thiobutabarbital, bradykinin infusion (5 microg/kg per minute I.A.) resulted in a rapid decrease in mean arterial pressure (MAP) of about 20 mm Hg (P<.01, n=9), although MAP slowly increased by 10 mm Hg after 15 minutes. When Ang-(1-7) (20, 80, and 380 nmol per rat I.A.) was given during bradykinin infusion, it elicited hypotension at 80 and 380 nmol (deltaMAP: -15+/-2.7 and -21+/-3.3 mmHg, respectively; P<.001); this hypotension was not affected by the angiotensin type 1 antagonist L-158,809 (200 microg/kg I.A.), the angiotensin type 2 antagonist PD 123319 (10 mg/kg I.A.), saralasin, or sarthran (10 microg/kg per minute). The bradykinin type 2 receptor antagonist icatibant (30 microg per rat) eliminated the hypotensive responses to Ang-(1-7), which now increased MAP at all doses tested (P<.005). Thus in the presence of bradykinin, Ang-(1-7) induces hypotensive responses that are blocked by icatibant and unaffected by angiotensin receptor antagonists. Ang-(1-7) given to saline-infused rats elicited hypertensive responses at all doses (deltaMAP: 6.4+/-1.5, 12+/-1.6, and 16.3+/-2.7 mmHg, respectively; P<.01); these responses were abolished by L-158,809 and sarthran. In rats pretreated with saralasin, Ang-(1-7) induced hypotension at 80 and 380 nmol (deltaMAP: -7.7+/-2.3 and -9.5+/-2.7, respectively; P<.05), whereas icatibant abolished this response. Thus in the rat, Ang-(1-7) can decrease blood pressure by a mechanism involving the bradykinin type 2 receptor and participates with bradykinin in a vasodepressor pathway that may serve a counterregulatory role, modulating the vasoconstrictor effects of Ang II.

A total of 174 E. coli isolates collected from healthy poultry, bovine and ovine recovered between December 2009 and June 2013 in different geographic location in Tunisia, were assessed and examinated for resistance to antimicrobial agents. Avian isolates showed the highest rates of antibiotic resistance: tetracycline (74.7 %), trimethoprim/sulfamethoxazole and amoxicillin with the same rate of resistance (57 %). Prevalences of resistance to the same four antimicrobials in bovine isolates were 33.3 %, 65 %, 30 %, 28.3 %, respectively. However, for ovine isolates, low resistance rates were observed, except for tetracycline (40 %) and amoxicillin (22.85 %). Only one ESBL-producing isolate from chicken was detected. In addition, seventy-seven (44.2 %) isolates were resistant to three or more classes of antibiotics and were considered multidrug resistant (MDR). Interestingly, avian E. coli isolates were more resistant than bovine and ovine ones. These results provide novel insights into the epidemiological characteristics of poultry, bovine and ovine E.coli isolates in Tunisia, and suggest the need for the prudent use of antimicrobial agents in husbandry and the urgent need to establish a national antibiotic resistance monitoring program.

This case-control study examined the prevalence of enteroaggregative Escherichia coli (EAEC), its genes and elicited inflammatory response, and the stool characteristics of adult patients with and without acute diarrhoeal illness presenting to an urgent-care clinic in the USA. A total of 1004 individual stool specimens (253 from patients with acute diarrhoeal illness and 751 from patients without diarrhoeal illness) were collected between 1 June 2003 and 30 June 2008. EAEC was identified as the sole cause of acute diarrhoeal illness in 6 % (n515) of patients and in 2 % (n515) without diarrhoeal illness. Control patients (n515) were similar to case patients (n515) for age, gender and co-morbidities. The EAEC genes aggR, aap, aat, astA and/or set1A were identified more frequently in case patients compared with control patients (P ,0.05). aggRpositive EAEC elicited higher levels of interleukin (IL)-1ra, IL-6, IL-8 and tumour necrosis factor-a compared with aggR-negative EAEC during co-incubation with HCT-8 cells. Patients with EAEC diarrhoea and isolates with the genes aggR, aap, aatA, astA or set1A had stools characterized by gross mucus and the presence of faecal leukocytes (P ,0.05). These results indicate that EAEC is a potential cause of acute diarrhoeal illness affecting patients presenting to an acute-care clinic in the USA and suggest that aggR, aap, aatA, astA and set1A may be markers for virulence.

Study DesignProspective observational study.PurposeTo assess the clinical outcome after early versus late decompression for traumatic cervical cord injury.Overview of LiteratureTraumatic spinal cord injury is common globally with the most tragic outcomes in the cervical spine. Although recent studies have shown that early decompression results in more favourable outcome, its authority is yet to be established.MethodsStudy on 98 patients with a traumatic cervical cord injury was conducted over a period of 5 years. The patients who were operated on within 24 hours of the onset of the primary injury (n=34) were classified as the early group, and those who were operated on after 24 hours of the onset of the injury (n=64) were categorized as the late group. The outcome of both the groups was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) at the 6-month follow-up.ResultsThe patients in the early group were operated on at a mean time of 18.4 hours (range, 13-24 hours) while patients were operated on at a mean time of 52.7 hours (range, 31-124 hours) in the late group. At the 6-month follow-up, 7 (23.3%) in the early group and 5 (8.7%) in the late group showed >2 grade improvement in the AIS.ConclusionsThe results of patients undergoing decompression within 24 hours of the injury are better than those who are operated on later. An attempt should be made to decompress the traumatic cervical spine early in all possible cases.

Introduction: Traumatic intracerebral contusion is a frequent factor culminating in death and disability, and its progression relates to unfavorable outcome. We evaluated the radiological factors associated with hemorrhagic progression of contusions (HPC). Materials and Methods: Two hundred and forty-six patients were enrolled in this prospective cohort over a period of 1 year. Contusion volume was quantified using the “ABC/2” technique, whereas progression was considered as >30% increase in the initial volume. Univariate and multivariate statistics were used to examine the correlation between the risk factors of interest and HPC. Results: HPC was seen in 110 (44.7%) patients. Binary logistic regression showed in the final adjusted model that multiplicity (relative risk [RR]: 2.24, 95% confidence limit [CL]: 1.00–5.48), bilateral lesions (RR: 2.99, 95% CL: 1.08–8.25), initial volume of contusion (RR: 4.96, 95% CL: 1.87–13.13), frontal location (RR: 1.42, 95% CL: 1.08–3.56), and presence of concomitant intracranial hematoma (extradural-RR: 3.90, 95% CL: 1.51–10.01, subdural-RR: 2.91, 95% CL: 1.26–6.69, and subarachnoid-RR: 2.27, 95% CL: 1.01–5.80) were significantly associated with HPC. The overall mortality was 18.7% and was almost equal among patients with and without HPC. Mortality was significantly associated with Glasgow Coma Scale on admission (adjusted RR: 12.386, 95% CL: 4.789–32.035) and presence of comorbid conditions (adjusted RR: 0.313, 95% CL: 0.114–0.860). Conclusion: Initial computed tomography scan is a good predictor of high-risk group for HPC.

Objective:The objective was to assess depression as comorbidity among patients of diabetes mellitus (DM) using Beck Depression Inventory II (BDI II) scale. Materials and Method: A cross sectional survey was conducted in Pakistan for 3 months targeting patients of diabetes mellitus DM and assessing their depression as a comorbidity using BDI II questionnaire. Data analysis was carried out using SPSS version 20. Descriptive statistics, cross tabulation and Chi square (X 2 ) tests were employed. Results: Majority of the target group was normal (N=58, 28%) while a quarter of the sample suffers from mild depression (N=54, 26.1%). Some suffered from moderate depression (N=43, 20.8%) followed by a tenth of segment who suffered from severe depression (N=20, 9.7%). Few were reported to suffer from extreme episodes of depression (N=4, 1.9%). The depression was also statistically associated with patients' BMI (<0.05), disease duration (<0.01), family history (<0.01) and glycated haemoglobin Hb A1c (<0.01). Conclusion: Likelihood of suffering from depression in DM is high. Modifiable factors i.e. BMI, HBA1c, etc. and non modifiable factors of DM such as genetic predisposition and disease duration play an important role in occurrence of depression as comorbidity. Educating the patients about DM can prove effective in dealing with the disease and its complications since patients will be prepared and be taught aggressive self management which may also prove helpful in managing comorbid depression.

Study DesignA prospective study on spinal tuberculosis (TB) at a tertiary care hospital in an endemic region.PurposeThe aim of the study is to reiterate the importance of conservative management of spinal TB.Overview of LiteratureSpinal tuberculosis can present with wide spectrum of symptoms, with back pain being the most common symptom. It is the leading cause of non-traumatic paraplegia in developing countries. There is an emerging trend to operate on patients early with spinal TB.MethodsForty-seven (M=14, F=33) patients were enrolled in the study during the four year study period. Initially, all the patients were subjected to computed tomography guided percutaneous needle aspiration (PCNA) followed by antituberculous therapy (ATT) for 12 months. Indications for surgery included patients with moderate to severe symptoms in which PCNA either failed, was impossible to carry out, or produced minimal improvement within 48 hours.ResultsPresenting complaints included pain (95.7%), weakness (85.1%) and sphincter involvement (12.8%). On the magnetic resonance imaging, a paravertebral abscess was seen in 37 (78.7%), disc and body destruction in 29 (61.7%), and an epidural abscess in 12 (25.9%) patients. Of the 47 patients, 9 (19.1%) required surgery, 4 of whom had failed PCNA attempts and 5 demonstrated indications despite successful PCNA.ConclusionsThe results of conservative treatment consisting of PCNA and ATT for at least 12 months in compliant patients are excellent. A combined approach using clinical staging, PCNA, and ATT can minimize surgical intervention in most patients. However, ATT remains to be the cornerstone of management of spinal TB.