Natural history of asymptomatic gallstones: differential behaviour in male and female subjects

OBJECTIVE

The natural history of asymptomatic (silent) gallstones has been inadequately studied. Existing information derives from studies based on oral cholecystography or relatively small sample sizes. We planned a retrospective cohort study in subjects with gallstones to determine conversion rates from asymptomatic to symptomatic.

METHODS

We extracted data from computerised databases of one government hospital and two private clinics in Malaysia. Files were scrutinised to ensure that criteria for asymptomatic gallstones were fulfilled. Patients were called on telephone, further questioned to confirm that the gallstones at detection were truly asymptomatic, and asked about symptoms that were consistent with previously defined criteria for biliary colic. Appropriate ethical clearances were taken.

RESULTS

213 (112 males) patients fulfilled the criteria for asymptomatic gallstones and could be contacted. 23 (10.8%) developed pain after an average follow up interval of 4.02 years (range 0.1-11 years). Conversion rates from asymptomatic to symptomatic gallstones were high in the first two years of follow up, averaging 4.03±0.965 per year. Over time the conversion rates slowed, and by year 10 the annual conversion rate averaged only 1.38±0.29. Conversion rates were much higher for females compared to males (F:M hazard ratio 3.23, SE 1.54, p>z 0.014). The lifetime risks for conversion approached 6.15% for males, and 22.1% for females.

CONCLUSION

In conclusion, asymptomatic gallstones are much more likely to convert to symptomatic in females than in males. Males in whom asymptomatic stones are discovered should be advised conservative treatment. Surgery may be preferable to conservative management if the subject is a young female.

Economic cost of malaria on households during a transmission season in Khartoum State, Sudan

This study was conducted in 2004 among 1200 households in Khartoum to estimate the direct and indirect economic costs of malaria for households. Information on the household and the malaria episodes was collected (care-seeking behaviour, working days lost and expenditure on malaria treatment). There were 327 episodes of malaria; 25.2% of the households reported at least 1 malaria episode during the month preceding the survey. In only 18.0% of malaria episodes was the individual economically active. The average treatment expenditure per fully cured case was US$ 6.3 (SD 5.9). The average indirect cost per fully cured case was U.S. $3.2 (SD 9.2); it was higher for individuals working in the informal sector than those employed in the formal sector.

Spontaneous spinal epidural hematoma causing cord compression after streptokinase and heparin therapy for acute coronary artery occlusion

We have reported a case of spinal epidural hematoma with cord compression in a 49-year-old man treated with short-term streptokinase and continuous heparin infusion. The sudden onset of back pain with subsequent neurologic deficits in a patient treated with fibrinolytic therapy alone or in combination with an anticoagulant should prompt an evaluation for spinal epidural hematoma with associated cord compression. The risk of combined fibrinolytic and anticoagulant therapy is not clear and warrants further evaluation.