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An unsolved problem of laparoscopic cholecystectomy is the optimal method of removing the gallbladder with thick walls and a large stone burden. Proposed solutions include fascial dilatation, stone crushing, and ultrasonic, high-speed rotary, or laser lithotripsy. Our observation was that extension of the fascial incision to remove the impacted gallbladder was time efficient and did not increase postoperative pain. We reviewed the narcotic requirements of 107 consecutive patients undergoing laparoscopic cholecystectomy. Fifty-two patients required extension of the umbilical incision, and 55 patients did not have their fascial incision enlarged. Parenteral meperidine use was 39.5 +/- 63.6 mg in the patients requiring fascial incision extension and 66.3 +/- 79.2 mg in those not requiring fascial incision extension (mean +/- standard deviation). Oral narcotic requirements were 1.1 +/- 1.5 doses vs 1.3 +/- 1.7 doses in patients with and without incision extension, respectively. The wide range of narcotic use in both groups makes these apparent differences not statistically significant. We conclude that protracted attempts at stone crushing or expensive stone fragmentation devices are unnecessary for the extraction of a difficult gallbladder during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Background: Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique., Methods: Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces., Results: The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions., Conclusion: This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up., (© Hobday et al.)

Background: Post-partum haemorrhage is the leading cause of maternal deaths in Mozambique. In 2015, the Mozambican Ministry of Health launched the National Strategy for the Prevention of Post-Partum Haemorrhage at the Community Level. The strategy included the distribution of misoprostol to women in advance at antenatal care and via Traditional Birth Attendants who directly administer the medication. The study explores the role of Traditional Birth Attendants in the misoprostol program and the views of women who used misoprostol to prevent post-partum haemorrhage., Methods: This descriptive study collected data through in-depth interviews and focus group discussions. Traditional Birth Attendants between the ages of 30-70 and women of reproductive age participated in the study. Data was collected between June-October 2017 in Inhambane and Nampula Provinces. Line by line thematic analysis was used to interpret the data using Nvivo (v.11)., Results: The majority of TBAs in the study were satisfied with their role in the misoprostol program and were motivated to work with the formal health system to encourage women to access facility based births. Women who used misoprostol were also satisfied with the medication and encouraged family and friends to access it when needed. Women in the community and Traditional Birth Attendants requested assistance with transportation to reach the health facility to avoid home births., Conclusions: This study contributes to the evidence base that Traditional Birth Attendants are an appropriate channel for the distribution of misoprostol for the prevention of post-partum haemorrhage at the community level. More support and resources are needed to ensure Traditional Birth Attendants can assist women to have safe births when they are unable to reach the health facility. A consistent supply of misoprostol is needed to ensure women at the community level receive this life saving medication.

Achieving Sustainable Development Goal targets for 2030 will require persistent investment and creativity in improving access to quality health services, including skilled attendance at birth and access to emergency obstetric care. Community-based misoprostol has been extensively studied and recently endorsed by the WHO for the prevention of post-partum haemorrhage. There remains little consolidated information about experience with implementation and scale-up to date. This narrative review of the literature aimed to identify the political processes leading to WHO endorsement of misoprostol for the prevention of post-partum haemorrhage and describe ongoing challenges to the uptake and scale-up at both policy and community levels. We review the peer-reviewed and grey literature on expansion and scale-up and present the issues central to moving forward.

In 2007 Timor-Leste, a malaria endemic country, changed its Malaria Treatment Protocol for uncomplicated falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. The change in treatment policy was based on the rise in morbidity due to malaria and perception of increasing drug resistance. Despite a lack of nationally available evidence on drug resistance, the Ministry of Health decided to change the protocol. The policy process leading to this change was examined through a qualitative study on how the country developed its revised treatment protocol for malaria. This process involved many actors and was led by the Timor-Leste Ministry of Health and the WHO country office. This paper examines the challenges and opportunities identified during this period of treatment protocol change.

Purpose: The aim was to assess awareness of diabetes mellitus and its ocular complications among Timorese aged 40 years and older., Methods: An interview-based questionnaire was administered to a subset of five urban and five rural clusters of 45 people aged 40 years and older as part of a population-based cross-sectional survey., Results: The participation rate was 96.2 per cent and data were analysed for 413 respondents. Correct nomination of at least one symptom, risk factor, prevention or treatment of diabetes was made by 6.1 per cent of participants. When explicitly asked, 6.8 per cent thought that diabetes caused problems with the body and 3.6 per cent thought diabetes caused eye problems., Conclusion: There is little awareness of diabetes and its ocular complications in Timor-Leste. Given the predicted urbanisation and economic development in the coming decades, as other health challenges are addressed and resources become available, consideration of diabetes might be prudent. Improving knowledge among the population will be an important component of any strategy developed., (© 2012 The Authors. Clinical and Experimental Optometry © 2012 Optometrists Association Australia.)

The immunoperoxidase technique was used with antibodies against B-cell-associated antigens, including CD20, CD79a, CD10, CD23, CD43, cyclin D1, bcl-2, and kappa and lambda immunoglobulin light chains on formalin-fixed and B5-fixed tissue sections of follicular, small lymphocytic, mantle cell, and marginal zone lymphomas. Results obtained with paraffin section immunohistochemistry for CD20, CD10, CD23, and kappa and lambda light chains were compared with results obtained with flow cytometry or frozen section immunohistochemistry. Cells in all of the lymphoma types were positive for CD20 and CD79a. The antigenic profiles of the B-cell lymphomas demonstrated in paraffin sections were lymphoma type distinctive. Intrafollicular lymphocytes in follicular lymphomas were positive for CD10 and bcl-2. Small lymphocytic lymphomas expressed CD43 and CD23 and were negative for CD10 and cyclin D1. Mantle cell lymphomas characteristically expressed CD43 and cyclin D1 and were negative for CD23 and CD10. Marginal zone lymphomas were negative for CD23, CD10, and cyclin D1. All of the antibodies performed better in B5-fixed tissues, but formalin-fixed tissue immunophenotypes were always similar to those obtained on the B5-fixed tissue. These results were possible using well-fixed tissue, various antigen retrieval strategies, paraffin section reactive primary antibodies, and sensitive detection systems. Paraffin section immunohistochemistry on sections of routinely fixed tissue can be used similarly to flow cytometry and frozen section immunohistochemistry when classifying the lymphomas of small B lymphocytes.

Suramin is an experimental chemotherapeutic agent which produces a severe dose-related neuropathy. Suramin inhibits axonal growth from rat dorsal root ganglion neurons. This inhibition is dose dependent and reversed by increasing nerve growth factor concentrations. In this study, myelinating dorsal root ganglion cultures were exposed to various concentrations of suramin and nerve growth factor. Effects were assessed with quantitative light and electron microscopy. Using a systematic sampling technique, suramin was observed to produce dose and time-dependent myelinated fiber degeneration. With 9-day exposure, there was no effect with suramin concentrations of 100 microM or less. At 200 microM, 17% of the myelinated fibers were degenerating at 4 days and 53.3% by 9 days. At 300 microM, 72.7% of the myelinated fibers and at 1316 microM, 88.7% of the myelinated fibers were degenerating at 4 days. It appeared that secondary demyelination was the major process. Large multilamellar inclusion bodies filled Schwann cells, particularly those investing unmyelinated fibers and dorsal root ganglia neuron cell bodies. The size and frequency of these inclusions increased with prolonged exposure to suramin (300 microM). Immunohistochemistry revealed that the inclusions were composed primarily of GM1 ganglioside. These effects were not influenced by increasing nerve growth factor up to 500 ng/ml. We conclude that suramin causes injury to both axons and Schwann cells that is not prevented by NGF and produces and experimental form of GM1 gangliosidosis.

While much of the clamor over the optimal instrument for dissection of the gallbladder from the liver bed has died, there remain no prospective comparative data concerning this issue. We undertook a prospective randomized trial comparing the contact neodymium:YAG laser with monopolar electrosurgical dissection in 100 patients undergoing laparoscopic cholecystectomy. Electrosurgical dissection was performed with an "L" hook and spatula electrodes at 25 W coagulation current. Neodymium:YAG laser dissection was performed with a 1200-microns contact tip at 15 W continuous beam. Mean (+/- SD) gallbladder dissection time was 19.2 +/- 8.5 minutes with electrosurgery compared with 23.6 +/- 9.6 minutes with the laser. Estimated blood loss was significantly less in the electrosurgery-treated group. In six instances, laser malfunction or fiber fragmentation necessitated completing the dissection with electrosurgery. We conclude that electrosurgery appears to have significant advantages for dissection of the gallbladder during laparoscopic cholecystectomy.

Use-effectiveness of the Billings Ovulation Method (OM) is reported for 1139 clients from six centers who were followed for at least 24 months. Method failure rates were 1% when calculated by either Pearl formula or life table analysis. Combined method and user failure rates were 20% when calculated with the Pearl formula, and 16% at 12 months and 23% at 24 months by life table analysis. Pregnancy rates were higher for couples using OM alone, than for couples using OM in combination with additional fertility awareness methods or together with barrier methods. The difference was significant when estimated by the Pearl formula but not when analyzed by the life table. The emotional implications underlying the apparent contradiction between a desire to avoid pregnancy and the deliberate coital use of fertile days are reflected in the differences between method and user failure rates, the high client satisfaction levels reported with "user failure," and 56% continuation rate at 24 months. The will require in-depth exploration.

The authors review research describing family dynamics in adolescent chemical abuse and dependency. Family systems theory is outlined, suggesting that family members, parents in particular, be included in accurate diagnosis and effective treatment. The pediatrician is viewed as having a relationship of trust with parents, being in a unique position to provide counsel, direction, and referral. Specific treatment strategies are recommended and illustrated with case studies.