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Background: The management of stones in the common bile duct in the laparoscopic era is controversial. The three major options are preoperative endoscopic retrograde cholangiography (ERCP), laparoscopic exploration of the common bile duct (LECBD), or postoperative ERCP.Methods: Between August, 1995, and August, 1997, 471 laparoscopic cholecystectomies were done in our department. In 427 (91%), satisfactory peroperative cholangiography was obtained. In 80 (17%) of these cases there were stones in the common bile duct, 40 patients were randomised to LECBD and 40 to postoperative ERCP. If LECBD failed, patients had either open exploration of the common bile duct or postoperative ERCP. If one postoperative ERCP failed, the procedure was repeated until the common bile duct was cleared of stones or an endoprosthesis was placed to prevent stone impaction. The primary endpoints were duct-clearance rates, morbidity, operating time, and hospital stay. Analyses were by intention to treat.Findings: Age and sex distribution of patients was similar in the randomised groups. Duct clearance after the first intervention was 75% in both groups. By the end of treatment, duct clearance was 100% in the laparoscopic group compared with 93% in the ERCP group. Duration of treatment was a median of 90 min (range 25-310) in the laparoscopic group (including ERCPs for failed LECBD) compared with 105 min (range 60-255) in the postoperative ERCP group (p = 0.1, 95% CI for difference -5 to 40). Hospital stay was a median of 1 day (range 1-26) in the laparoscopic group compared with 3.5 days (range 1-11) in the ERCP group (p = 0.0001, 95% CI 1-2).Interpretation: LECBD is as effective as ERCP in clearing the common bile duct of stones. There is a non-significant trend to shorter time in the operating theatre and a significantly shorter hospital stay in patients treated by LECBD. [ABSTRACT FROM AUTHOR]

SummaryBackground: Abdominal pain of uncertain aetiology (non-specific abdominal pain; NSAP) is the commonest reason for emergency surgical admission. The aim of this study was to examine the role of early laparoscopy in the management of NSAP. Methods: Some 120 patients, admitted between November 1995 and October 1998 with acute abdominal pain of uncertain aetiology, were randomized into two groups: group 1 had laparoscopy during the first 18 h of admission and group 2 had close observation, conventional investigation and surgical intervention if signs of peritonism developed. Outcome measures were diagnosis, operative procedures, duration of hospital stay, readmission rate, morbidity and death, patient satisfaction and total number of investigations performed. Results: Median hospital stay was 2 (range 1–13) days in both groups (P = 0·87). A diagnosis was established in 48 (81 per cent) of 59 patients in group 1 compared with 22 (36 per cent) of 61 in group 2 (P < 0·0001). The morbidity rate was 14 (24 per cent) of 59 in group 1 and 19 (31 per cent) of 61 in group 2 (P = 0·3629). The readmission rate at a median follow-up of 21 (range 1–35) months was 17 (29 per cent) of 59 in group 1 compared with 20 (33 per cent) of 61 in group 2 (P = 0·6375). Well-being scores improved from 134 on admission to 149 of 177 6 weeks later in group 1 (P = 0·007) and from 132 to 143 of 177 in group 2 (P = 0·089). Conclusion: Early laparoscopy provided a higher diagnostic accuracy and improved quality of life in patients with NSAP. [ABSTRACT FROM AUTHOR]

Aims: To find a possible correlation of Ki67 antigen and proliferating cell nuclear antigen (PCNA) with prognosis in anorectal malignant melanoma. Methods and results: Thirty patients with anorectal malignant melanoma were studied. The percentage of tumour cells stained for Ki67 and PCNA in paraffin sections was assessed. Mode of treatment (local excision or abdominoperineal resection), depth of tumour invasion, attempt at cure as defined by complete tumour excision and absence of distant metastases at presentation, tumour blood vessel invasion, and tumour necrosis, as well as Ki67 and PCNA, were all correlated with survival. By univariate analysis, PCNA, Ki67, attempt at cure, local excision (and not abdominoperineal resection), and depth of invasion were all significantly associated with longer survival. By multivariate analysis, only PCNA was significantly associated with survival, while Ki67 showed a significant positive correlation with PCNA. With a cut-off point of 40%, patients with lower Ki67 scores showed survival advantage over those with higher Ki67 scores (P =0.0004). With a cut-off point of 80%, patients with lower PCNA scores showed survival advantage over those with higher PCNA scores (P =0.0001). The staining for proliferation markers was also associated with depth of tumour invasion. Conclusions: Ki67 and PCNA immunostaining in paraffin sections may be useful for the prediction of survival in patients with anorectal malignant melanoma. Larger studies are needed to confirm our results. [ABSTRACT FROM AUTHOR]

This study describes the prevalence of positive SARS-CoV-2 test results among asymptomatic pregnant women presenting for labor and delivery at Yale New Haven health system hospitals. [ABSTRACT FROM AUTHOR]

The article describes two cases of transmission of lymphocytic choriomeningitis virus (LCMV) and an LCMV-like arenavirus via organ transplantation from a common donor in Massachusetts in 2008 that were reported to the U.S. Centers for Disease Control & Prevention (CDC). The kidney donor was a man aged 49 years with a history of alcohol abuse. The first recipient was a woman aged 70 years with end-stage renal disease caused by nephrotic syndrome while the second was a man aged 57 years with end-stage renal disease caused by hypertension.

Hospital blood glucose (BG) management is a challenge. We implemented an electronic health record (EHR)-based system at our 1541-bed academic medical center (AMC), alerting when a patient (pt) experiences significant hyperglycemia (hyper; 2 BGs ≥300 mg/dL over 48 hours) or hypoglycemia (hypo; <70 mg/dL). These Excursion Event Alerts (EEAs) fired to the clinician entering orders and provided links to insulin order sets and consult requests. The EEAs were launched on 14 non-ICU wards in mid-2019. We compared BG control during the 3 months prior to launch vs. the most recent 3 months. The control group consisted of 12 non-EEA wards. Our 1° outcome was the Quality Hyperglycemia Score-2 (QHS2), previously developed to assess/compare the overall BG quality on individual wards. QHS2 (scale, 0-100) incorporates 5 elements of BG management, crediting overall control as well as the minimization of significant fluctuations. After the intervention, there was a substantial 13.8% improvement in mean QHS2 (+9.36, p=0.029), comprised of more pt-days in target (+4.3%, p=0.024) and a trend for less pt-days with severe hyper (-2%, p=0.09), with no change in hypoglycemia. In contrast, there was no change in QHS2 on control wards. We conclude that a glycemic alert system was associated with improved BG control at our large AMC, suggesting that a simple EHR-based intervention can favorably impact hospital diabetes management. Disclosure: L.B. Bak: None. T.M. Fandel: None. J.E. Bozzo: None. M.L. DeWitt: None. P. Chen: None. R.A. Pando: None. L. Ferro: None. R. Kaplan: None. K.C. Hendrickson: None. S.B. Amport: None. L. Sussman: None. S.E. Inzucchi: Advisory Panel; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Lexicon Pharmaceuticals, Inc., Novo Nordisk A/S, Sanofi. Consultant; Self; Abbott, Merck & Co., Inc., vTv Therapeutics. [ABSTRACT FROM AUTHOR]