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Background: This study estimates the number of laparoscopic cholecystectomies required until improvement ceases, assesses the magnitude of such improvement, and provides some insight into the mechanism by which it takes place. Methods: Data from 500 consecutive laparoscopic cholecystectomies were analyzed from a prospective data base for number of short and long operations and operative time. Results: There was a 40% decrease (P

Background: This study examines the contribution of increased laparoscopic skills to ambulatory management of perforated appendicitis. Methods: All 38 perforated appendicitides from 151 laparoscopic appendectomies done by one surgeon were studied and ambulatory management (discharge less than 24 hours after surgery) of the last 18 perforations reported. Results: Over 4 years, rate of attempted laparoscopic appendectomy rose from 67% to 100% for perforations. Conversion rate fell from 100% to 22%. Ileus and pain control were not problems for most laparoscopic perforations, so by the end of 1997, experience suggested these patients might be discharged within 24 hours. Ambulatory rate was 57% (conversions excluded). There were no readmissions for wound infections or postoperative abdominal abscesses. Conclusions: Increasing laparoscopic skills allows laparoscopic treatment of complicated appendicitis with a low conversion rate and no infectious complications. Over one half of these patients can be managed as outpatients without jeopardy to outcome.

Poliomyelitis surveillance in India previously involved the passive reporting of clinically suspected cases. The capacity for detecting the disease was limited because there was no surveillance of acute flaccid paralysis (AFP). In October 1997, 59 specially trained Surveillance Medical Officers were deployed throughout the country to establish active AFP surveillance; 11,533 units were created to report weekly on the occurrence of AFP cases at the district, state and national levels; timely case investigation and the collection of stool specimens from AFP cases was undertaken; linkages were made to support the polio laboratory network; and extensive training of government counterparts of the Surveillance Medical Officers was conducted. Data reported at the national level are analysed and distributed weekly. Annualized rates of non-polio AFP increased from 0.22 per 100,000 children aged under 15 years in 1997 to 1.39 per 100,000 in 1999. The proportion of cases with two adequate stools collected within two weeks of the onset of paralysis increased from 34% in 1997 to 68% in 1999. The number of polio cases associated with the isolation of wild poliovirus decreased from 211 in the first quarter of 1998 to 77 in the first quarter of 1999. Widespread transmission of wild poliovirus types 1 and 3 persists throughout the country; type 2 occurs only in Bihar and Uttar Pradesh. In order to achieve polio eradication in India during 2000, extra national immunization days and house-to-house mopping-up rounds should be organized.

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.

The immunogenicity of trivalent oral poliovirus vaccine (TOPV), which is less effective in tropical than in temperate areas, may potentially be improved in several ways, including increasing the number of doses. Little information is available on TOPV when more than 6 doses are given. The situation in Cuba provides a unique opportunity to relate the seroprevalence of neutralizing antibodies to the dose of TOPV because Cuba has not reported culture-confirmed poliomyelitis since 1973 and TOPV is only administered in twice yearly 1-week mass immunization campaigns. Sera from 2000 children nationwide were studied for neutralizing antibody among children who received 0, 2, 4, 6 and 8 doses of TOPV. These doses were administered in the period 1989-91, when TOPV (from the USSR) was being used with 500,000, 200,000, and 300,000 median tissue-culture-infecting doses (TCID50) for types 1, 2 and 3, respectively--the 5:2:3 formulation. Seroprevalence of neutralizing antibody after two TOPV doses was 91.5% for type 1, 90.8% for type 2, and 45.9% for type 3. Seroprevalence of type-3 neutralizing antibody after 6 doses remained low (73.4%), but increased to 83.5% after 8 doses (P0.05). Although 16.5% of the children remained unprotected for type-3 infection even after 8 doses, mass campaign immunization strategies were sufficient to eradicate the transmission of wild poliovirus in Cuba. Because the seroprevalence of type-1 neutralizing antibody was high (91.5%) after two campaign doses, additional studies using different formulations are needed to determine whether simultaneous improvement in the type-3 response to two campaign doses can be achieved.During December 1991-January 1992 in Cuba, health workers took blood samples from a nationwide sample of 2000 children aged 0-3 who received 0, 2, 4, 6, and 8 doses of trivalent oral poliovirus vaccine (TOPV) to determine the seroprevalence of poliovirus neutralizing antibodies for types 1, 2, and 3. Specifically, researchers wanted to learn whether TOPV becomes more effective as the number of doses increases. Since 1973, Cuba has conducted two mass immunization campaigns each year in February and April. During 1970-91, Cuba used a USSR-produced poliovirus vaccine that had 500,000, 200,000, and 300,000 median tissue-culture-infecting doses for types 1, 2, and 3, respectively. Wild poliovirus has not been transmitted in Cuba since 1973 (as of August 1993), indicating that the mass immunization campaigns without routine vaccine delivery have eradicated poliomyelitis in Cuba. The seroprevalence of poliovirus neutralizing antibodies for type 1 increased significantly between 2 and 4 doses (91.5% vs. 96.5%; p = 0.05), thereafter the increases were small and insignificant. The seroprevalence of poliovirus neutralizing antibodies for type 2 increased significantly between 2 and 4 doses (90.8% vs. 97.2%), with small insignificant increases thereafter. Two doses of TOPV induced a response against poliovirus type 3 in only 45.9% of cases. At 4 doses and 8 doses, it did increase significantly from the previous dose (71.2% and 83.5%, respectively; p 0.05). Further studies using other vaccine formulations would allow persons involved in global eradication efforts to determine whether two campaign doses can improve the immunogenicity of the type 3 poliovirus while also improving that of the type 1 poliovirus.