School of Medicine

Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence Background: Acute appendicitis remains the most common cause of the acute abdomen in young adults, and the mainstay of treatment in most centres is an appendectomy. However, treatment for other intra-abdominal inflammatory processes, such as diverticulitis, consists initially of conservative management with antibiotics. The aim of this study was to determine the role of antibiotics in the management of acute appendicitis and to assess if appendectomy remains the gold standard of care. Methods: A literature search using MEDLINE and the Cochrane Library identified studies published between 1999 and 2009, and we reviewed all relevant articles. The articles were critiqued using the Public Health Resource Unit (2006) appraisal tools. Results: Our search yielded 41 papers, and we identified a total of 13 papers within the criteria specified. All of these papers, while posing pertinent questions and demonstrating the role of antibiotics as a bridge to surgery, failed to adequately justify their findings that antibiotics could be used as a definitive treatment of acute appendicitis. Conclusion: Appendectomy remains the gold standard of treatment for acute appendicitis based on the current evidence. Contexte : L'appendicite aiguë demeure la plus fréquente cause de l'abdomen aigu chez les jeunes adultes et dans la plupart des centres, la base du traitement repose sur l'appendicectomie. Toutefois, le traitement des autres processus inflammatoires intraabdominaux, comme la diverticulite, consiste initialement en une prise en charge conservatrice par antibiothérapie. Cette étude avait pour but de déterminer le rôle des antibiotiques dans la prise en charge de l'appendicite aiguë et de vérifier si l'appendicectomie reste la norme thérapeutique. Méthodes : Une interrogation des publications dans MEDLINE et la Collaboration Cochrane a permis de recenser des études publiées entre 1999 et 2009 et nous avons passé en revue tous les articles pertinents. Nous avons soumis les articles à un examen critique en appliquant les outils d'évaluation de la Public Health Resource Unit (2006). Résultats : Notre recherche a retrouvé 41 articles, et nous avons retenu 13 articles à partir des critères spécifiés. Tous, même s'ils posaient des questions pertinentes et établissaient le rôle de l'antibiothérapie comme étape de transition avant la chirurgie, ont échoué à démontrer de façon adéquate leurs conclusions selon lesquelles les antibiotiques pourraient être utilisés en traitement définitif de l'appendicite aiguë. Conclusion : Si l'on se fie aux preuves actuelles, l'appendicectomie reste la norme thérapeutique privilégiée pour le traitement de l'appendice aiguë. A cute appendicitis is inflammation of the vermiform appendix and remains the most common cause of the acute abdomen in young adults. The mainstay of treatment in most centres is an appendectomy, and, consequently, this is one of the most common operations performed on the acute abdomen. 1 However, appendicitis can be notoriously difficult to diagnose, and there exists a negative appendectomy rate of 10%-20% despite the use of preoperative computed tomography (CT). 2-6 In addition, as with all operations, postoperative complications exist, including wound infections, intra-abdominal abscesses, ileus and, in the longer term, adhesions. With this in mind, it is worth considering that the mainstay of treatment for

Introduction: Recent advancements in the management of colorectal liver metastases have resulted in an improvement in survival. Novel biomarkers such as KRAS, and their mutations potentially predict the response of biological therapies such as cetuximab (Erbitux). This paper evaluates the use of cetuximab in the first-line management of colorectal liver metastases. Methods: An electronic literature search was performed of publications within the past 6 years. The following key words, singly or in combination, were used: KRAS, cetuximab, metastatic colorectal cancer and colorectal liver metastases. All randomized controlled trials and cohort studies were included. Results: Fifteen prospective studies reviewed the clinical application of cetuximab. Seven studies included subgroup analysis of KRAS mutational status, with only one study performed prospectively. Until the MRC COIN trial, the evidence consistently demonstrated cetuximab significantly improved progression-free survival, overall survival and surgical resection rates, especially in KRAS wild-type tumours. However, the MRC COIN trial found cetuximab had no additional benefit when combined with standard chemotherapy. Conclusions: The literature does not support the routine use of cetuximab as the standard first-line treatment of colorectal liver metastases, rather highlighting the need for the optimization of treatment on an individual basis, especially depending on tumour KRAS status.

Increased life expectancy has led to the presentation of more complicated patients in old age for the replacement of the aortic valve. The emergence of Transcatheter Aortic Valve Implantation (TAVI) was considered as a significant breakthrough in the management of symptomatic, moribund patients suffering from aortic valve stenosis who had been rejected for surgical intervention. A novel technology often has a long journey from the point at which it is created to its everyday use. It is now obvious that TAVI practice in multiple institutes around the world has gone beyond the evidence. Serious concerns have been raised questioning the current TAVI practice. Analysis of future TAVI use may assist clinicians and healthcare managers to understand and deploy this technology in accordance with the evidence.

Resting state activity in the ventral cingulate may be an important neural marker of symptomatic improvement in depression. The number of task related functional magnetic resonance imaging (fMRI) studies correlating blood oxygenation level dependent (BOLD) response with symptomatic improvement is limited and methodologies are still evolving. We measured BOLD responses to sad and happy facial stimuli in 12 severely depressed individuals in the early stages of antidepressant treatment (Time 1) and 12 weeks later (Time 2) using event-related fMRI. We calculated correlations between temporal changes in BOLD response and changes in symptom scores. Most subjects improved markedly by Time 2. At Time 1, depression severity correlated positively with responses to sad stimuli in the right visual cortex, subgenual cingulate, anterior temporal pole and hippocampus and correlated negatively with responses to happy stimuli in left visual cortex and right caudate. Decreases in individual effect sizes of right subgenual cingulate and right visual cortical responses to sad, but not happy, facial stimuli were correlated with decreases in symptom scores. There are contrasting cortical and subcortical responses to sad and happy stimuli in severe depression. Responses to sad stimuli show the strongest correlates of clinical improvement, particularly in the subgenual cingulate.

Background: Anhedonia is a relative lack of pleasure in response to formerly rewarding stimuli. It is an important diagnostic feature of major depressive disorder (MDD), and predicts antidepressant efficacy. Understanding its neurobiological basis may help to target new treatments and predict treatment outcomes. Using a novel paradigm, we aimed to explore the correlations between anhedonia severity and magnitude of neural responses to happy and sad stimuli in regions previously implicated in studies of human reward processing and depressive anhedonia. Methods: Neural responses to happy and sad emotional stimuli (autobiographical prompts and mood congruent facial expressions) were measured using blood oxygen level dependent (BOLD) functional magnetic resonance imaging in twelve MDD individuals with varying degrees of anhedonia. Results: In response to happy stimuli, anhedonia, but not depression severity per se, was positively and negatively correlated with ventromedial prefrontal cortex (VMPFC) and amygdala/ventral striatal activity, respectively. State anxiety independently contributed to a VMPFC-subcortical dissociation of response to happy (but not sad) stimuli, which was similar, but different, to anhedonia. Conclusions: These findings suggest that anhedonia and state anxiety are associated with dysfunction within neural systems underlying the response to, and assessment of, the rewarding potential of emotive stimuli in MDD, and highlight the importance of employing a symptom-dimension-based approach in the examination of the neurobiology of depression.

Background: Anhedonia is a relative lack of pleasure in response to formerly rewarding stimuli. It is an important diagnostic feature of major depressive disorder (MDD), and predicts antidepressant efficacy. Understanding its neurobiological basis may help to target new treatments and predict treatment outcomes. Using a novel paradigm, we aimed to explore the correlations between anhedonia severity and magnitude of neural responses to happy and sad stimuli in regions previously implicated in studies of human reward processing and depressive anhedonia. Methods: Neural responses to happy and sad emotional stimuli (autobiographical prompts and mood congruent facial expressions) were measured using blood oxygen level dependent (BOLD) functional magnetic resonance imaging in twelve MDD individuals with varying degrees of anhedonia. Results: In response to happy stimuli, anhedonia, but not depression severity per se, was positively and negatively correlated with ventromedial prefrontal cortex (VMPFC) and amygdala/ventral striatal activity, respectively. State anxiety independently contributed to a VMPFC-subcortical dissociation of response to happy (but not sad) stimuli, which was similar, but different, to anhedonia. Conclusions: These findings suggest that anhedonia and state anxiety are associated with dysfunction within neural systems underlying the response to, and assessment of, the rewarding potential of emotive stimuli in MDD, and highlight the importance of employing a symptom-dimension-based approach in the examination of the neurobiology of depression.

Background: Accurate recognition of facial expressions is crucial for social functioning. In depressed individuals, implicit and explicit attentional biases away from happy and toward sad stimuli have been demonstrated. These may be associated with the negative cognitions in these individuals. Methods: Using event-related functional magnetic resonance imaging (fMRI), neural responses to happy and sad facial expressions were measured in 14 healthy individuals and 16 individuals with major depressive disorder.

Background: Altered white matter microstructure in tracts integral to mood regulation networks could underlie vulnerability to major depressive disorder (MDD). Guided by fMRI studies, we explored whether a positive family history of MDD (FH+) and anhedonia (reduced capacity for pleasure) were associated with altered white matter microstructure in the cingulum bundles and uncinate fasciculi.
Methods: Thirty four healthy female student volunteers (mean age 22 years) were recruited by advert. Exclusion criteria included other current or previous psychiatric disorder, current depression, and current psychotropic medication. FH was determined using established criteria. DT-MRI data were acquired on a 3T GE Signa scanner. Fibre tractography was performed for each individual for a priori tracts of interest, and corticospinal tracts. Mean Fractional Anisotropy (FA), an index of microstructure, was calculated for each tract.
Results: Tracts were reconstructed in 18 FH+ individuals and 15 FH- individuals, who did not differ by age or subclinical depressive symptoms. FH+ individuals had 3-5% lower fractional anisotropy (FA) in the right and left cingulum bundles than FH- individuals (p=0.012, p=0.059, respectively). Post hoc analysis demonstrated 8% lower FA in the left subgenual cingulate (p=0.007). Hedonic tone correlated positively with FA in the right and left cingulum bundles (r=0.342, p=0.052; r=0. 477, p=0.005, respectively), and the left subgenual cingulum (r=0.500, p=0.003).
Conclusions: Both family history of MDD and subclinical anhedonia are associated with reduced FA in the bilateral cingulum bundles, but particularly in the left subgenual cingulum. Altered cingulum white matter architecture is implicated in the aetiology of MDD.

The delivery of aff ordable and equitable cancer care is one of India's greatest public health challenges. Public expenditure on cancer in India remains below US$10 per person (compared with more than US$100 per person in high-income countries), and overall public expenditure on health care is still only slightly above 1% of gross domestic product. Out-of-pocket payments, which account for more than three-quarters of cancer expenditures in India, are one of the greatest threats to patients and families, and a cancer diagnosis is increasingly responsible for catastrophic expenditures that negatively aff ect not only the patient but also the welfare and education of several generations of their family. We explore the complex nature of cancer care systems across India, from state to government levels, and address the crucial issues of infrastructure, manpower shortages, and the pressing need to develop cross-state solutions to prevention and early detection of cancer, in addition to governance of the largely unregulated private sector and the cost of new technologies and drugs. We discuss the role of public insurance schemes, the need to develop new political mandates and authority to set priorities, the necessity to greatly improve the quality of care, and the drive to understand and deliver cost-eff ective cancer care programmes.

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Savlon (0.5% cetrimide/0.05% chlorhexidine) is used as a scolicidal during surgery of hydatid cysts. It is considered a safe and effective agent. However, there are no recommendations for the appropriate concentration or dosage of these agents. Previously reported to cause severe metabolic acidosis, its effects on the pulmonary system have not been explored. We present a case of acute lung injury and respiratory distress along with acute cardiopulmonary distress, severe metabolic acidosis, and renal failure following its use during surgical removal of pulmonary hydatid cyst. The agent may act as a chemical sclerosant causing pulmonary parenchymal damage through bronchial openings present in the pericyst. Till safe dose limits are known, use of this agent should be limited, especially in large or multiple cyst surgery.

Patient satisfaction is as important as is the care itself. When the patient has a disease like cancer it becomes even more important. A cancer patient not only suffers from the disease but also undergoes substantial mental trauma, agony, stress, uncertainty, and apprehension. There are limited studies in India eliciting patient's views on the quality of care being received by cancer patients. A cross-sectional triangulation data transformation model mixed method design (Quant + Qual) was used to conduct the study between March and May 2015 among patients attending specialty hospitals providing oncology services in Odisha, India. The quantitative data were collected using, Patient Satisfaction Questionnaire-18 to assess satisfaction. The qualitative data were obtained through in-depth interviews using open-ended questionnaire. The results showed that general satisfaction among the patients was 60%. The maximum score was obtained for the communication of doctors. The qualitative ...