Department of Health and Human Services OFFICE OF INSPECTOR GENERAL PART D BENEFICIARIES WITH QUESTIONABLE UTILIZATION PATTERNS FOR HIV DRUGS Daniel R. Levinson Inspector General August 2014 EXECUTIVE SUMMARY: Part D Beneficiaries With Questionable Utilization Patterns for HIV Drugs, OEI-02-11-00170
Even if Viagra is not needed, it is possible that the doctor will be able to determine the etiology of erectile dysfunction and prescribe appropriate treatmen https://sydneyrx2014.com.au it doesn't pay to forget about sexual activeness even at the first sings of malfunction.
Wjes.orgYahya et al. World Journal of Emergency Surgery 2014, 9:12http://www.wjes.org/content/9/1/12 WORLD JOURNAL OF EMERGENCY SURGERY The role of emergency surgery in hydatid liverdisease Ali I Yahya*, Hussen E Shwereif, Mustafa A Ekheil, Ahmed S Thoboot, Kalid A Algader, Fatma O Gyaedand Abdsalem S Aldarat Hepatic hydatid disease is very common in Libya. In Zliten hospital, we operated 400 patients with hepatic hydatidcysts over period of 20 years. All patients were symptomatic. Their ages varied from 3 to 85 years including 215female and 185 male patients. Their symptoms varied from abdominal pain to abdominal mass 67 patients wereadmitted through Accident and Emergency Department with acute presentations including fever, skin rash,jaundice and shock with acute abdominal pain. Those 67 patients had necessary investigations, resuscitation andunderwent emergency surgery. The hepatic cysts in all patients were excised, and the obstructive jaundice wascleared in those patients with obstructive jaundice. Unfortunately, one of the patients died two days after thesurgery because of multiple organ failure (MOF) Morbidity was wound Infection, bile leak and recurrence rate wereall reported in our series.
Keywords: Liver, Hydatid disease, Emergency surgery Methods and materials Hydatid is a disease caused by tape worm called ecchi- The files of the patients were reviewed retrospectively.
nococcous granulosis and ecchinococcous multilocularis.
Four hundred patients were operated at the general Hydatid disease is endemic in some regions in the world surgery department at Zliten hospital while sixty seven and Libya is one of the endemic countries of hydatid dis- patients were operated as emergency because of their ease among the Middle East countries. This disease is acute presentations, the research was approved by the common in sheepherder regions. Thus people who live research and ethical committee in the hospital.
thereare accidentally infected. Dogs are the definitive 67 patients were admitted through Accident and host and sheep is the intermediate host. Human gets the Emergency Department. One of them was shocked and infection by eating contaminated vegetables by dogs' admitted to the surgical ICU. All the patients came waste or by direct contact with dogs. Infection rate is from endemic areas of hydatid disease. Routine investi- higher in places where dogs are fed with infected car- gations were done including complete blood count, casses and offal. Liver is the commonest organ involved blood group, blood sugar, urea and electrolytes. Liver in human as well as lung, kidneys,spleen, bones and soft function tests and ultrasound scan were done for all tissues. Symptoms depend on the size of the cyst, the patients. CT scan was also performed for most of the organ involved and the complications from the cyst.
patients. All the patients had intravenous fluid, antibi- The diagnosis of hydatid liver disease depends on history otics, analgesia and hydrocortisone.
and clinical examination. Using imaging investigations is All patients had laparotomy at same day. The opera- very valuable to confirm the diagnosis including ultrasound tions were done under general anesthesia through right scan and CT scan. While serological investigations are not subcostal incision. Precautions were taken to prevent needed in endemic area, surgical intervention is the main spillage of the cyst content. Intraoperative ultrasound way to treat hepatic hydatid cysts.
was done routinely for all patients to find out the exactnumber of cysts. The duration of surgeries varied from * Correspondence: one and half an hour to three hours. All the cysts were General surgery department, Zliten Teaching Hospital and Edwaw District Hospital, Zliten, Libya 2014 Yahya et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited.
Yahya et al. World Journal of Emergency Surgery 2014, 9:12 and rigid. The patient had resuscitation including IV fluid, Group A - 45 patients were presented with abdominal IV hydrocortisone and IV analgesia. He had routine inves- pain and obstructive jaundice. Blood tests showed high tigation and the ultrasound scan showed hydatid cyst liver bilirubin and alkaline phosphates while other blood tests in the left lobe with a lot of fluid in the abdomen. The pa- were normal. The ultrasound showed hepatic hydatid cysts.
tient had laparotomy and there was a big hydatid cyst at 23 patients were with single big cyst with no daughter the left lobe which was ruptured. With excision of the cyst cysts. All cysts were near to the hilum with size ranges and cleaning of the abdominal cavity, the patient im- from 10 to 15 cm. In 9 patients, the cysts were in the left proved and discharged in good conditions.
lobe and in the other 14 patients, they were in the right Group E - Ten patients were admitted with abdominal lobe. Bile ducts were normal in size.
pain and fever. They had ultrasound scan which showed In 22 patients, the ultrasound showed cysts with mul- hydatid cysts of the liver. In seven patients, the cysts tiple daughter cysts. In twenty one of them, the cysts were at the right lobe and in three patients at the left were in the right lobe and in one patient, the cyst was in lobe. Laparotomy was performed for all of them. The the left lobe. The size of cysts ranges from 8 to 15 cm.
cysts were full of pus, and the cyst cavity was completely MRCP was done for two patients and it showed clear cleared. Drain was inserted and the patients were cov- communication between the cyst and the biliary tree.
ered with antibiotics. Patients improved and discharged Preoperative ERCP was done for one patient who was in in good conditions.
septicemia and renal impairment. 23 patients, with their Group F - A female Patient was 35 years old was ad- cysts near the hilum, were excised and the fluid in the mitted with dyspnea and chest pain. On clinical examin- cyst was clear. There were no bile and no daughter cysts ation, the patient looked pale and dyspnic with rapid but only single endocyst. There was no bile duct com- pulse and decrease air entry on the right side of the munication and the cyst cavity was completely closed.
22 patients were with cysts at the right and the left X-ray of the chest showed that the right side was lobe of the liver. Those cysts contain multiple daughter pleural effusion. The ultrasound of the abdomen showed cysts. Some of them contain bile stained fluid. After re- huge hydatid cyst in the right lobe of the liver with a lot moval of all daughter cysts, there were communications of daughter cysts in the right chest cavity. The CT scan with bile ducts. With the use of the Fogarty catheter, of abdomen and chest confirmed the finding of hydatid daughter cysts and membranes came out. We flushed cyst liver ruptured into chest. The patient had routine the bile ducts with huge amount of saline and the com- investigations and urgent surgery. The finding was a munication was closed with 2/0 PDS.
huge cyst in the right lobe of the liver full of daughter Group B -Two patients (one is male 18 years and the cysts and bile, ruptured into the chest cavity. Wound ex- other is female 24 years old) were presented with swell- tended into the right thoracotomy and the hepatic cyst ing at anterior abdominal wall. Both the swellings were was excised and the fistula closed washing the pleural tender red, ultrasound findings in both patients showed cavity. Drains were inserted and common bile duct was that hydatid cyst liver communicating with the abdom- cleared from daughter cysts. The patient discharged in inal swellings which were cystic. Both patients had good conditions.
laparotomy and excision of the hydatid cysts and the Group G - Two patients had laparotomy for hepatic abscess track. Both patients cured and discharged in hydatid cyst (one of them was male 18 years and the good conditions.
other was female 25 years old). The male Patient was Group C - Six patients were admitted with skin rashes diagnosed with huge right hepatic lobe hydatid cyst.
all over the body. Two of them were males and the MRCP showed big communication with cyst and the others were females ageing between 16 to 25 years.
patient was not jaundiced. He had a laparotomy and ex- General conditions were stable and their blood pressure cision of the cyst. The communication with bile duct was within normal. On abdominal examination, there was closed and the patient discharged in good condi- was guarding and tenderness all over the abdomen. The tions. After 10 days from the surgery, the patient came ultrasound examination showed huge hydatid cysts in back to the hospital with abdominal pain. He looked the liver and all were in the right lobe with free fluid in dehydrated, sick and hypotensive. Routine investigations the abdomen. 6 patients underwent urgent laparotomy showed leucocytosis and raised bilirubin 3.3 mg with a and excision of the hydatid cysts. There was leak from slight increase of alkaline phosphates. The ultrasound the cysts into the abdominal cavity, but patients im- showed that the abdomen was full of fluid. The patient proved and discharged in good conditions.
had IV fluid, IV antibiotics and laparotomy was done.
Group D - One patient was admitted to Intensive Care The abdomen was full of bile and it was cleaned com- Unit with shock. On examination, patient looked sick, pale pletely. There was a leak from the cyst cavity and a and tachycardiac with low BP. Abdomen was guarding big drain was inserted into the cyst cavity. Then the
Yahya et al. World Journal of Emergency Surgery 2014, 9:12 abdomen was closed and the patient improved and dis- Discussion and conclusion charged in good conditions.
Sixty seven patients with hepatic hydatid cysts were ad- The female patient had laparotomy for the hydatid cyst mitted through Accident and Emergency Department of liver. After three days, she developed severe abdominal Zliten hospital with acute symptoms. They were oper- pain. On examination, the abdomen was guarding and ated urgently and their presentations were as follow: tender. The ultrasound showed plenty of fluid in the ab-domen. The patient was sick and urgent laparotomy was A. 45 patients with obstruction jaundice.
done to her. The abdomen was full of bile, it was washed B. 2 patients with abdominal wall abscess.
with plenty of saline and a big drain was inserted in the C. 6 patients with skin rash.
cyst cavity. And the patient improved and discharged in D. 1 patient with anaphylactic shock.
E. 10 patients with liver abscess.
Sixty seven patients with hepatic hydatid cysts were F. 1 patient with biliopleural fistula.
admitted to our surgery ward with acute presentations G. 2 patients with biliary peritonitis following hepatic included obstructive jaundice which was 11.25% of the hydatid cystectomy.
total hydatid liver cysts operated in our institute. Sixpatients were presented with skin rash and acute ab- Liver is the commonest organ gets infected by ecchinoco- dominal pain was 1.25% of the total patients admitted cous granulosis. The cyst can be asymptomatic discovered and operated in Zlien hospital. Two patients were on routine ultrasound examination of the abdomen, or treated in the hospital with abdominal wall abscess symptomatic like abdominal mass or abdominal pain which is fistula with hydatid liver cyst which was 0.5%.
Hepatic cyst can be seen or discovered as organized cyst While ten patients were presented with liver abscess during investigations or other abdominal operations. In which was 2% of the total patients treated. One patient endemic areas, any patient, comes with the right upper ab- was presented with anaphylactic shock and another dominal mass, is considered infected with hydatid cyst liver patient with bilipleaural fistula. Whereas another two until it is proved otherwise. Surgery is the main treatment patients were presented with peritonitis followed hep- for hepatic hydatid cyst. Most of our patients were treated atic hydatid cyst excision. Those sixty seven patients electively. Sixty seven patients (67) with acute symptoms underwent resuscitation and routine necessary investi- were operated urgently to avoid complication such as rup- gations. All of them had urgent surgery and hepatic ture which was reported in the literatures of the patients cysts were excised. One of the patients died after two Different nonsurgical treatment was performed like days from the surgery due to multiple organ failure.
pair technique in different centers, but none of our patients The main hospital stay is 6 days. The morbidity noticed was candidate for pair technique Medical treat- among 400 operated patients. 6% of them suffered ment like albendazole (antihelmentic) is used in treatment from bile leak, 4% with wound infection and 2% with of hepatic hydatid cysts. Some centers used the medical recurrence (Figure treatment and good results were observed. But in our cen-ter, we did not report significant benefits of medical treat-ment. We used albendazole preoperative and postoperativeto prevent recurrence and antihelmintic. Medical treatmentis not beneficial for patients with acute presentation wheretime makes difference in management. We also used med-ical treatment postoperatively for our patients to preventrecurrence. Sixty seven patients who came to the Accidentand Emergency Department had routine investigations andultrasound scan, and they were treated by urgent laparot-omy through the right Kocher incision. Patients of groupA, with obstructive jaundice, the obstruction was done bycompression on bile duct from outside and obstructionfrom inside by daughter cysts and parasitic membraneNone of the patients had preoperative ERCP Figure 1 Distribution of patients presentations. A-45 patients Only four of them had ERCP postoperatively for continu- with obstruction jaundice. B-2 patients with abdominal wall abscess.
C-6 patients admitted with skin rash. D-One patient with anaphylactic ous bile leak through the drain. ERCP will not cure them shock. E-10 patients with liver abscess. F-1 patient with biliopleural fistula.
but it will only clear the bile ducts from intraductal obstruc- G-2 patients with biliary peritonitis following hepatic hydatid cystectomy.
tion by daughter cysts or parasitic membrane and will relief Group A=1, Group B=2, Group C=3, Group D=4, Group E=5, Group F=6, the jaundice before surgery. The patient will still need surgery to cure him or her from the disease. We explored Yahya et al. World Journal of Emergency Surgery 2014, 9:12 the common bile duct through the communication with Accident and Emergency Department. Those patients were the cyst for those in whom the obstructive jaundice is intra- sick and they had the investigations and treatment done ur- ductal. But those in whom the obstruction is extra ductal gently. They were presented with different acute presenta- the obstruction is cleared with excision of the cyst. We tions such as obstructive jaundice, skin rashes, anaphylactic reviewed the literatures of the patients. Most of the patients shock, abdominal wall abscess, liver abscess, peritonitis and underwent ERCP before surgery. Patients of group B suf- biliopleural fistula. All of them had urgent surgeries and fered from abdominal wall swelling due to fistulization of could not be treated by medical or PAIR treatment. As superficial laying hepatic hydatid cyst. Rare presentation usual, the complications from emergency surgery were ex- was also reported in literatures of patients with pected to be more. But in this research, the rate of compli- biliocutaneous fistula. Patients of group C were presented cations were not much different from the patients operated with skin rash and abdominal pain due to leakage of para- electively. This is due to emergency surgery done at the sitic fluid into the abdominal cavity which induced anaphyl- right time for the right patient.
actic reaction due to antigen antibody reaction. Thosepatients had minimal leak where they did not go into Competing interests anaphylactic shock. All of them had intravenous fluid and The authors declare that they have no competing interests.
hydrocortisone and underwent urgent laparotomy and Authors' contribution excision of hydatid cyst. While patients of group D were All authors read and approved the final manuscript.
presented with anaphylactic shock due to hydatid cyst. Butthis was very rare. Among four hundred patients operated Received: 12 March 2013 Accepted: 6 October 2013Published: 30 January 2014 in our institution, only three patients had anaphylacticshock, two of them had the shock during surgery and the other patient was case reported as emergency presentation.
Grosso G, Gruttadauria S, Biondi D, et al: Worldwide Epidemiology of LiverHydatidosis Including the Mediterranean Area. World J Gastroenterol 2012, The three patients were saved with use of intravenous adrenaline and intravenous fluid. Patients of group E were Kjossev K, Losanoff J: TNRC Classification for Liver Hydatid Cysts. Int Surg presented with liver abscess and secondary infection 1998, 83:311–313.
Kjossev K, Losanoff J: Response to Comment on ‘Classification of Hydatid by bacteria. Liver abscess was expected because of high Liver Cysts'. J Gastroenterol Hepatol 2007, 22(4):604.
temperature patients were sick and dehydrated. The Kjossev K, Losanoff J: Classification of Hydatid Liver Cysts. J Gastroenterol ultrasound showed that the cyst contents were thick. Liver Hepatol 2005, 20(3):35.
Kjossev K: Classification, Staging and Surgical Treatment. Sofia Bulgaria: PhD abscess was confirmed by surgery. All the patients had anti- biotics and only three of them had blood transfusion be- Dakkak A: Echinococcosis/Hydatidosis: A Severe Threat in Mediterranean cause of low hemoglobin. The patient of group F had very Countries. Vet Parasitol 2010, 174(1–2):2–11.
Akcan A, Akyildiz H, Artis T, et al: Peritoneal Perforation of Liver Hydatid rare presentation. The hepatic hydatid cyst infiltrated the Cysts Clinical Presentation, Predisposing Factors, and Surgical Outcome.
diaphragm and opened in the pleura. Patients of group G World J Surg 2007, 31(6):1284–1291.
had urgent surgeries. The two patients had biliary periton- Dumnici A, Papiu H, Olariu T: Acute Surgical Abdomen Produced by anAbdominalized Infected Gigantic Hydatid Cyst. Case Reports. English itis after hepatic hydatid cyst surgery. They were diagnosed Abstract. J Article Chirurgia (Bucur) 2004, 99(3):181–184.
clinically and underwent urgent surgery. The usual time of Durif S, Marinkovic Z, Febvre C, et al: Hydatid Liver Disease Revealed by surgery varies from one hour to 3 hours and the patients Surgical Acute Abdominal Syndrome. Case Reports, English Abstract,Journal Article. Arch Pediatr 2005, 12(11):1617–1619.
had excision of the cyst and closure of the cyst cavity. But Gogia N, Sharma R, Gamangatti S, et al: Hepatic Hydatid cysts with biliary, none of them had liver resection although they had big and peritoneal rupture and transdiaphragmatic migration. Case reports, drain inserted around the cyst area which left for 3 to Journal article. Trop Gastroenterol 2006, 27(2):93–96.
Ghesquière F, Mourot N, Olivero de Rubiana JP, et al: Surgery of Hepatic 5 days. Emergency surgery gives quick answer to patient Hydatic Cyst. Per-operative Complications. Possibility of Anaphylactic with acute complain. Only one patient died. She had Etiology. Case Reports, English Abstract, Journal Article. Anesth Analg obstructive jaundice and died because of multiple organ (Paris) 1979, 36(11–12):561–563.
Daradkeh S, EL-Muhtaseb H, Farah G: Predictors of Morbidity and Mortality failure. We reported morbidity includes bile leak, wound in the Surgical Management of Hydatid Cyst of the Liver. Arch Surg 2007, infection, recurrence. Hospital stay was longer for patients who had emergency surgery in comparison to elective Kang MJ, Lee SH, Kim SJ, et al: A Case of Multiple Intraperitoneal CystsFrom Ruptured Hepatic Hydatid Cysts. Case Reports, English Abstract, Journal Article. Korean J Gastroenterol 2007, 50(3):203–206.
Ozturk G, Aydinli B, Yildirgan MI, et al: Posttraumatic Free Intraperitoneal Rupture of Liver Cystic Echinococcosis: a Case Series and Review ofLiterature. Journal Article 2007, 194(3):313–316.
Hepatic hydatid disease can be asymptomatic or symptom- Haddad M, Al Awar G, Jalbout R, Kanj V, Elkattah R, Faraj W, Khalifeh MJ: atic with usual symptoms either abdominal pain or abdom- New Trends in the Management of Hepatic Echinococcusgranulosus.
inal mass. We reviewed our patients admitted and treated Libya 2011, 59(3):154–159.
Filippou D, Tselepis D, Filippou G, Papadopoulos V: Advances in in Zliten institution. Most of them were admitted and LiverEchinococcosis: Diagnosis and Treatment. Clin Gastroenterol Hepatol treated electively 67 patients were admitted through the Yahya et al. World Journal of Emergency Surgery 2014, 9:12 Dziri C, Haouet, Fingerhut A: Treatment of Hydatid Cyst of the Liver:WhereIs the Evidence? World J Surgery 2004, 28(8):731–736.
Liver Echinococcosis, Consensus Statement of The National Conference,Sofia. 2003.
Papadimitriou J, Mandrekas A: The Surgical Treatment of Hydatid Diseaseof the Liver. Br J Surg 2005 XII, 57(6):431–433.
Nunnari G, Pinzone M, Gruttadauria S, et al: Hepatic Echinococcosis: clinicaland the Rapeutic Aspects. World J Gastroenterol 2012, 18–13:1448–1458.
Mandal S, Mandal M: Human cystic echinococcosis: epidemiologic,zoonotic, clinical, Diagnostic and Therapeutic Aspects. Asian Pac J TropMe 2012, 5(4):253–260.
Ivanov G: Modern Approach in Diagnosis and Surgical Treatment of Liver.
Echinococcosis in children and Adults. Varna, Bulgaria: PhD Dissertation;2012:182.
Lu SF, Li JZ: Cases of Hydatid Disease of the Common Bile Duct. JournalArticle. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bing ZaZhi 2000,18(3):185.
Manterola C, Barroso M, Vial M, Bustos L, Muñoz S, Losada H, Bello N,Hernández F, Carrasco R: Liver Abscess of Hydatid Origin: Clinical Features andResults of Aggressive Treatment. 2003.
Prousalidis J, Kosmidis C, Kapoutzis K, et al: Intrabiliary Rupture of HydatidCysts of the Liver. Journal Article. Am J Surg 2009, 197(2):193–198.
Târcoveanu E, Vasilescu A, Moldovanu R, Vlad N, Rusu V, Stanciu C: UnusualForms of Liver Abscesses. Rev Med Chir Soc Med Nat Las, 112(3):688–697.
Coyle WJ: ERCP in Hepatic Hydatid Disease. [Comment, Journal Article].
Gastroenterol Rep 2004, 6(4):272.
Florea M, Barbu ST, Crisan M, et al: Spontaneous External Fistula of aHydatid Liver Cyst in a Diabetic Patient. Case Reports, Journal Article.
Chirurgia (Bucur) 2008, 103(6):695–698.
Losada H, Bello N, Hernández F, Carrasco R: Liver Abscess of Hydatid Origin:Clinical Features and Results of Aggressive Treatment. 2003.
Manterola C, Barroso M, Vial M, Bustos L, Muñoz S, Losada H, Bello N,Hernández F, Carrasco R: Liver Abscess of Hydatid Origin: Clinical Featuresand Results of Aggressive Treatment. ANZ J Surg 2003, 73(4):220–224.
doi:10.1186/1749-7922-9-12Cite this article as: Yahya et al.: The role of emergency surgery inhydatid liver disease. World Journal of Emergency Surgery 2014 9:12.
Submit your next manuscript to BioMed Central
and take full advantage of:
• Convenient online submission
• Thorough peer review
• No space constraints or color ﬁgure charges
• Immediate publication on acceptance
• Inclusion in PubMed, CAS, Scopus and Google Scholar
• Research which is freely available for redistribution
Submit your manuscript at www.biomedcentral.com/submit
Published Ahead of Print on March 8, 2010 as 10.1200/JCO.2009.24.4798 JOURNAL OF CLINICAL ONCOLOGY Prediction of Risk of Distant Recurrence Using the 21-GeneRecurrence Score in Node-Negative and Node-PositivePostmenopausal Patients With Breast Cancer Treated WithAnastrozole or Tamoxifen: A TransATAC StudyMitch Dowsett, Jack Cuzick, Christopher Wale, John Forbes, Elizabeth A. Mallon, Janine Salter, Emma Quinn,Anita Dunbier, Michael Baum, Aman Buzdar, Anthony Howell, Roberto Bugarini, Frederick L. Baehner,and Steven Shak