Self explanatory
The steps leading to the formation of adhesions and some of the factors that can influence the development of adhesions during surgery are illustrated.
How adhesions develop:
The tissue surface becomes damaged, either through surgery or injury, leading to disruption of the mesothelial lining
Bleeding and leakage of plasma proteins lead to fibrin deposits at injured sites, which is augmented by post-traumatic inflammation
The enlarging fibrin mesh might attach to an adjoining surface, a process that is counteracted by locally generated fibrinolytic factors
Depending on local peritoneal conditions, the fibrin mesh could either be degraded, resulting in scarless repair, or transformed into an adhesion consisting of connective tissue
If the fibrin is degraded within the first few days, the defect heals scarlessly
If remnants of fibrin remain for long enough, recruited reparative cells transform the initially reversible fibrinous adhesion to a fibrous, collagen-containing structure
Various factors can influence the development of adhesions during surgery - e.g. infection, heat, light, glove powder.
From the basic processes that result in the formation of adhesions, there are various steps that can be taken during surgery to minimise the risk of adhesions
These are:
increase vascular permeability
reduce infection risk
avoid GI contamination
minimise tissue handling by careful technique and microsurgery
reduce drying of tissues by using lubrication
limit use of cautery
limit use of sutures
avoid materials with fibres
use starch-free gloves
Although these measures will minimise the risks, they cannot eliminate the problem completely
Thus there is a clear need for improved adhesion-reduction strategies
Adhesion-reduction strategies involve:
Careful surgical technique
Minimisation of inflammatory response by use of
corticosteroids
NSAIDs
antibiotics
Augmentation of fibrinolysis
tissue plasminogen activator
Use of various adhesion-reduction agents
Risberg B. Eur J Surg 1997;577:32-39
Risberg reviewed a number of adhesion prevention strategies and techniques. The two major prevention strategies discussed are (1) adjusting surgical technique and (2) application of adjuvants.
NSAIDs (e.g. ibuprofen, tolmetin and oxyphenbutazone) can be applied systematically as well as intraperitoneally. Clinically efficacy remains questionable possibly because of drug delivery difficulties.
Corticosteroids (dexamethasone, hydrocortisone and prednisolone) can be administered intraperitoneally. Efficacy is doubtful due to associations with immunosuppression and delayed wound healing, e.g. infection, incisional hernia and wound dehiscence. Also, they do not remain in the peritoneal cavity for the duration of adhesion formation (4-5 days post surgery)
Fibrinolytics are designed to prevent or reverse fibrin deposition. Intraperitoneally or systematically administered plasminogen activator (tPA), streptokinase and elastase have undergone considerable laboratory evaluation with conflicting results, and in some cases, haemorrhagic complications. This lack of efficacy may be attributable to the problem of rapid peritoneal absorption and clearance.
To assess European opinion on post-operative adhesions two surveys were conducted, one at ESHRE 2002 (European Society of Human Reproduction and Embryology) and EACP (European Association of Coloproctology).
The respondents from ESHRE were all gynaecologists and results were as follows:
14.2% of respondents cited safety as an attribute associated with an ideal anti-adhesion agent
13.4% cited effectiveness
36.2% cited ease of use
15.7% cited low cost
Published in ANV 4
Note:
Preclude is referenced as ‘generally unavailable’ as clinical experience shows there are limitations in its use.
Hyskon is included in this slide as there is anecdotal evidence to suggest off-license use. However, cases of anaphylaxis have been recorded.
Mathias Korell – well recognised German gynae laparoscopy specialist has done studies with Spraygel and uses in endometriosis cases – where they do a lot of surgery (like colorectal in terms of extent of work in the abdomen – ie not neat and dainty stuff) and he is quoting need 5 kits to then coat the peritoneum to ensure adequate coverage – will be in Adhesions News & Vies Issue 5
Cost they quote around £150/sheet that would be a good size in abdominal surgery – but they won’t be more specific or detail how many sheets a colorectal surgeon might need to use
Adept® (icodextrin 4%) is a new potential solution to adhesions
Adept is approved throughout Europe for use in abdominal and pelvic surgery as an intraoperative wash and postoperative instillate for the reduction of adhesions
It is available as a 1 litre bag and most recently as a 1.5 litre bag to allow use of one bag for irrigating during surgery and to provide 1000ml to leave behind as a postoperative instillate
Work from a registry of routine use (ARIEL) which is now progressing in 150+ centres in Europe showed that a 1.5 litre presentation of Adept would be useful for most surgical cases allowing surgeons to irrigate with up to 500ml during surgery and then instil 1000ml to leave behind at the end of surgery
Icodextrin is a 1,4 linked glucose polymer
The structure is different from Dextran; the key difference lies in the linkage of carbon 1 and 4 (versus Dextran 1,6 which the human body cannot break down easily)
Icodextrin was developed from hydrolysis of corn starch (so it is a natural product)
Icodextrin is used for adhesion reduction as a 4% solution
This 4% solution is isosmolar and biocompatible with other drugs
Icodextrin is a large polymer and attracts a ‘water of hydration’ around it, increasing its size still further.
It is absorbed from the abdomino–pelvic cavity by the lymphatic system. In the blood it is broken down readily by amylase (acts on the 1,4 link) to maltose/isomaltose and then glucose, and is then excreted
Icodextrin has a well-established safety profile at the higher concentration of 7.5% where it is used in peritoneal dialysis - with > 36,000 patient years of safety data and use of Adept in >50,000 as at end January
Icodextrin was developed originally to overcome the issues associated with existing peritoneal dialysis fluids, specifically irritation to the peritoneum, etc
As a result of its structure, icodextrin with its ‘water of hydration’ stays in the abdomino–pelvic cavity over time (it is absorbed solely by the lymphatic system). It is this persisting presence in the abdomino–pelvic cavity that is thought to reduce adhesion formation/reformation as a result of ‘hydroflotation’
Hydroflotation is not a new concept, but the problem has been in finding a fluid that would stay in the abdomino–pelvic cavity long enough to keep tissues apart in the critical time after surgery when adhesions develop, but which does not have an irritant effect on the peritoneum, nor causes problems when absorbed (e.g. Dextran)
This slide looks at the persistence of 4% icodextrin over time compared to saline and glucose
It comes from a study in patients receiving peritoneal chemotherapy in whom 4% icodextrin was used as the carrier fluid1. In the periods between chemotherapy the icodextrin was used as a ‘dwell’ and aliquots drawn off through the Tenckhoff catheter
The results show that 50% of the icodextrin 4% solution was still retained after ~92+ hours, whereas within a day all the saline or glucose was absorbed by the lymphatics
This is the reason why crystalloid solutions such as saline are not very effective in the reduction of adhesions, as they do not stay in the abdomen for long enough to keep the organs and tissues ‘hydroflotated’
Reference
1. Hosie K, Gilbert JA, Kerr D et al. Fluid dynamics in man of an intraperitoneal drug delivery solution: 4% icodextrin. Drug Delivery 2001; 8: 9–12.
Video clips showing instillation at end of surgery
This slide shows the cost comparison of recent agents at current UK prices
Note the costs of agents is different in Finland but comparatively the relative price differentials will be the same
Two kits of Spraygel are often used to get adequate coverage of the surgical site and as per Prof Mathias Korell’s experience in major gynaecological surgery – 5 kits may be needed to ensure adequate coverage of the peritoneal cavity!
The US outcomes study with Seprafilm is using a mean 4.4 sheets/patients1
Intergel was withdrawn in April 2003
Reference
1. Beck DE, Cohen Z, Fleshman JW, Kaufman HS, vanGoor H, Wolff BG. Prospective, randomized, multicentre, controlled study of the safety of Seprafilm Adhesion Barrier in abdominopelvic surgery. Dis Colon Rectum 2003
This slide shows the cost comparison of recent agents at current UK prices illustrating costs of using 4.4 sheets Seprafilm (as per Beck) and 5 kits of Spraygel as (per Korell).
SurgiWrap not included as they don’t give a precise list price or how many sheets are used – when asked – and ?? Anyone using it yet??
Wilson MS et al. Colorectal Disease 2002;4:355-360
Wilson et al. modelled data from a lower abdominal surgery cohort from the SCAR data to assess cost effectiveness.
Results showed that:
Routine use of adhesion reduction products costing £50 per patient will payback the cost for such investment if they reduce adhesion-related readmissions by 16% after 3 years
A product costing £200 will need to offer a 64.1% reduction in readmissions after 3 years to recoup its direct costs
For the estimated 158,000 lower abdominal surgery operations conducted in the UK each year the cumulative costs of adhesion related readmissions over 10 years are estimated at £569 million
At year 3 – 64% reduction would be needed
And at 3 years
Wilson MS et al. Colorectal Disease 2002;4:355-360
Wilson et al. modelled data from a lower abdominal surgery cohort from the SCAR data to assess cost effectiveness.
Results showed that:
Routine use of adhesion reduction products costing £50 per patient will payback the cost for such investment if they reduce adhesion-related readmissions by 16% after 3 years
A product costing £200 will need to offer a 64.1% reduction in readmissions after 3 years to recoup its direct costs
For the estimated 158,000 lower abdominal surgery operations conducted in the UK each year the cumulative costs of adhesion related readmissions over 10 years are estimated at £569 million
This slide looks at cumulative costs of using an adhesion reduction agent over 9 years scaling up to the UK as a whole.
Using a £50 agent with a 25% efficacy would result in a saving of £71m
But using a £200 product with similar efficacy would result in a £142m loss – ie the health system would have to spend an extra £142m over the 9 years to reduce adhesion related readmissions by 25%.
In only 10.4% of cases were adhesions mentioned as part of the informed consent process
14.4% adhesions were discussed but not part of the consent
In those undergoing specific adhesiolysis operations 54% of patients reported being given some kind of information on adhesions before surgery
46% were given information on anti-adhesion agents
In procedures not involving adhesiolysis only 10% of patients reported receiving any adhesion information
Only 6% of cases were given information on anti-adhesion agents
Is this acceptable practice?
Most common adhesion-related claims
Failure to diagnose adhesion-related problems
Delay in diagnosis
Bowel damage at adhesiolysis
– laparoscopy > laparotomy
Infertility or risk of infertility
Starch granuloma – (use of starch-powdered gloves)
Failure to take precautions to prevent adhesions
1994 -1999 UK Medical Defence Union received 77 adhesion-related claims
Out of court settlements in 14 cases in 11 years ranged from £7960 - £124,261 (~€11,701 - €182,664)
– average £50,765 (€74,625)/case
And that was up until 1999
Since 1999
More evidence of burden of adhesions
SCAR study
Van Krabben enterotomy risk
SCAR-2
etc
Discuss high risk options then lead to prohylaxis
Before SCAR
Before we knew the real extent of the problem
Before we had newer anti-adhesion agents
Adhesions continue to be a significant burden
For the patient:
pain, SBO, infertility, re-operative complications
For the surgeon
increased workload, lengthy and complex procedures, medicolegal consequences
For the healthcare system
increased workloads, costs, bed stay
Where are we now?
Any advances in surgery have had little impact
Action on adhesions has received low priority
even in high risk procedures
New developments in anti-adhesion agents
not all are difficult or costly to use
emerging evidence of efficacy
Adopt use of anti-adhesion agents in ‘High Risk’ surgery
Adhesiolysis
Small bowel resection
Formation of stoma
Hartmann’s procedure
Anterior resection
Abdomino-perineal excision
Colectomy
Surgical treatment of peritonitis & fistulae
Thank you
Fellow SCAR Panel Members
Prof Harold Ellis, UMDS, London
Malcolm Wilson, Christie Hospital, Manchester
Don Menzies, Colchester Hospital, Colchester
Jeremy Thompson, Chelsea & Westminster Hospital, London
Brendan Moran, North Hampshire Hospital, Hampshire
Adrian Lower, St Bartholomew's Hospital, London
Rob Hawthorn, Southern General Hospital, Glasgow
Prof Alastair McGuire, City University, London
Graham Sunderland, Southern General Hospital, Glasgow
David Clark, James Boyd, Alan Finlayson, ISD, NHS Scotland, Edinburgh
Prof Ian Ford, Robertson Centre Biostatistics, Glasgow
Alastair Knight & Alison Crowe, Corvus
Shire Pharmaceuticals Group plc
Powerpoint template
Please read more
http://www.euuzlet.hu/koloproktologus/2004/parker.ppt.
Monday, June 30, 2008
Sunday, June 22, 2008
Do Men Get Adhesions?
...an informative look by David Wiseman PhD, MRPharmS, Founder, International Adhesions Society
It is a common myth that only women are prone to adhesions. While it is certainly true that women have more “internal parts” that require surgery, which inevitably leads to adhesions, men are not excluded from the problem of adhesions. A simple look at the national statistics collected from hospital discharges (ICD9 codes) from the most recent data available (2001-2005) reveals the following:
Over 50,000 men were discharged from hospital in 2005 with a diagnosis of peritoneal adhesions (568.0), accounting for 28% of such diagnoses, compared with 72% for women.
Over 37,000 men were discharged in 2005 with a diagnosis that included the specific diagnosis of intestinal adhesions with (ie causing) bowel obstruction (560.81). This number accounts for 38% of cases, compared with 62% for women.
Men also accounted for 37% of discharges with a principal diagnosis (as opposed to an incidental diagnosis) was intestinal adhesions with obstruction (560.81). Their length of stay was slightly higher than that of women in 3 of the five years studied and their hospital charges exceeded those of women in every year by as much as $2500.
Over 2000 men and women died every year with a diagnosis of intestinal adhesions with obstruction, representing about 3% of the total discharges with that diagnosis. The contribution of males to this death rate was in every year slightly higher than that of women in proportion to their discharges, by 10-15% in the years 2002-2005, and about 2% in 2001.
You can read more of this report by clicking here or visiting the Men's section on our website or the Downloads page.
Thank you to the International Adhesion Society
It is a common myth that only women are prone to adhesions. While it is certainly true that women have more “internal parts” that require surgery, which inevitably leads to adhesions, men are not excluded from the problem of adhesions. A simple look at the national statistics collected from hospital discharges (ICD9 codes) from the most recent data available (2001-2005) reveals the following:
Over 50,000 men were discharged from hospital in 2005 with a diagnosis of peritoneal adhesions (568.0), accounting for 28% of such diagnoses, compared with 72% for women.
Over 37,000 men were discharged in 2005 with a diagnosis that included the specific diagnosis of intestinal adhesions with (ie causing) bowel obstruction (560.81). This number accounts for 38% of cases, compared with 62% for women.
Men also accounted for 37% of discharges with a principal diagnosis (as opposed to an incidental diagnosis) was intestinal adhesions with obstruction (560.81). Their length of stay was slightly higher than that of women in 3 of the five years studied and their hospital charges exceeded those of women in every year by as much as $2500.
Over 2000 men and women died every year with a diagnosis of intestinal adhesions with obstruction, representing about 3% of the total discharges with that diagnosis. The contribution of males to this death rate was in every year slightly higher than that of women in proportion to their discharges, by 10-15% in the years 2002-2005, and about 2% in 2001.
You can read more of this report by clicking here or visiting the Men's section on our website or the Downloads page.
Thank you to the International Adhesion Society
Doctor performs rare surgery in Cedar Falls
By CJ HINES, Courier Correspondent
CEDAR FALLS --- Of the 11 cases of a rare laparoscopic surgery reported worldwide, one has been performed here in the Cedar Valley.Dr. J. Matthew Glascock, medical director for the Midwest Institute of Advanced Laparoscopic Surgery located at Sartori Memorial Hospital, heads the team of medical professionals who recently performed a laparoscopic Roux-ex-Y gastric bypass with visceral malrotation.Visceral malrotation is the twisting of the intestines, which occurs in the womb, Glascock said. While 75 percent of patients with malrotation are diagnosed by the age of 1, 25 percent aren't diagnosed until adulthood. These are usually discovered when the patient is undergoing another procedure or during an autopsy.While Glascock routinely performs the Roux-ex-Y gastric bypass operation, it is rare to perform one with a patient with visceral malrotation."It is an anomaly," Glascock said. "In normal anatomy, the person's large intestine frames the small intestines with the appendix in the lower righthand side of the abdomen. A person with visceral malrotation, everything is opposite. The large intestine and appendix are on the left side of the abdomen and the small intestine is on the right. The supporting structure never develops."Visceral malrotation occurs in 1 in 500 births in the United States, according to the Nemours Foundation, a national children's health care system and beneficiary of the Alfred I. duPont Testamentary Trust.Most people diagnosed with this condition have a Ladd's procedure during childhood, which involves removing the appendix and cutting the Ladd's bands, which are adhesions that attach from the beginning of the intestine to the abdominal wall.
The first gastric bypass patient identified with visceral malrotation had the surgery canceled and returned later for a gastric banding procedure.Approximately a year ago, Glascock encountered a second bypass patient with visceral malrotation while performing laparoscopic surgery. While the patient was still in the operating room, he discussed options with the patient's wife."Options offered were discontinuing surgery, changing the operation to adjustable gastric banding or converting to a laparotomy and attempting gastric bypass. The patient's wife elected converting from laparoscopy (done with scopes) to laparotomy (open incision) and gastric bypass with Ladd's procedure," said Sherri Greenwood, Sartori Hospital administrator and institute co-director. "The procedure was successfully completed."
Read More
http://www.wcfcourier.com/articles/2007/12/22/news/metro/c835535714319d50862573b9001492db.txt
CEDAR FALLS --- Of the 11 cases of a rare laparoscopic surgery reported worldwide, one has been performed here in the Cedar Valley.Dr. J. Matthew Glascock, medical director for the Midwest Institute of Advanced Laparoscopic Surgery located at Sartori Memorial Hospital, heads the team of medical professionals who recently performed a laparoscopic Roux-ex-Y gastric bypass with visceral malrotation.Visceral malrotation is the twisting of the intestines, which occurs in the womb, Glascock said. While 75 percent of patients with malrotation are diagnosed by the age of 1, 25 percent aren't diagnosed until adulthood. These are usually discovered when the patient is undergoing another procedure or during an autopsy.While Glascock routinely performs the Roux-ex-Y gastric bypass operation, it is rare to perform one with a patient with visceral malrotation."It is an anomaly," Glascock said. "In normal anatomy, the person's large intestine frames the small intestines with the appendix in the lower righthand side of the abdomen. A person with visceral malrotation, everything is opposite. The large intestine and appendix are on the left side of the abdomen and the small intestine is on the right. The supporting structure never develops."Visceral malrotation occurs in 1 in 500 births in the United States, according to the Nemours Foundation, a national children's health care system and beneficiary of the Alfred I. duPont Testamentary Trust.Most people diagnosed with this condition have a Ladd's procedure during childhood, which involves removing the appendix and cutting the Ladd's bands, which are adhesions that attach from the beginning of the intestine to the abdominal wall.
The first gastric bypass patient identified with visceral malrotation had the surgery canceled and returned later for a gastric banding procedure.Approximately a year ago, Glascock encountered a second bypass patient with visceral malrotation while performing laparoscopic surgery. While the patient was still in the operating room, he discussed options with the patient's wife."Options offered were discontinuing surgery, changing the operation to adjustable gastric banding or converting to a laparotomy and attempting gastric bypass. The patient's wife elected converting from laparoscopy (done with scopes) to laparotomy (open incision) and gastric bypass with Ladd's procedure," said Sherri Greenwood, Sartori Hospital administrator and institute co-director. "The procedure was successfully completed."
Read More
http://www.wcfcourier.com/articles/2007/12/22/news/metro/c835535714319d50862573b9001492db.txt
Friday, June 20, 2008
Fluid and pharmacological agents for adhesion prevention after gynaecological surgery
Fluid and pharmacological agents for adhesion prevention after gynaecological surgery
The use of fluids and pharmacological agents (medicinal drugs) to prevent the formation of adhesions (scar tissue) that may interfere with becoming pregnant after surgery of the female pelvis.
Adhesion formation is a condition in which bodily tissues that are normally separate grow together. This can occur after surgical procedures such as operations on the female pelvis to remove a cyst, treat endometriosis, remove a tubal pregnancy, or remove a fibroid (a benign tumour of the womb). This scar tissue can have serious effects on the woman's future fertility as it can lead to blockage of her tubes. Careful tissue handling at the time of surgery and control of the blood loss are important ways of reducing scar tissue, however, over the years other methods have been developed to minimise the risk of scar tissue formation. Surgeons have tried using different types of drugs or leaving different types of fluids inside the pelvis at the end of surgery to prevent tissue surfaces from sticking to each other. Fluids include dextran, icodextrin (Adept), SprayGel, and fluids containing the chemical hyaluronic acid (Intergel, auto-crosslinked hyaluronic acid, Sepracoat). Drugs that have been tried include steroids (anti-inflammatory drug), the anti-coagulant heparin, promethazine, and noxytioline.This review aimed to evaluate the role of these different agents in the prevention of adhesion formation. The results showed that there is currently insufficient evidence to recommend the use of steroids, icodextrin, SprayGel or dextran. The review did show that fluids that contained hyaluronic acid may help lower the chance of scar tissue forming; however, more studies are needed to confirm this. There are also some major safety issues concerning the use of one of these agents (Intergel), which has been withdrawn from the market due to reports of serious side effects such as allergic reactions and pain.A major problem with studies in this review is that most of them did not look at the rate of pregnancy following the use of these substances. Since the occurrence of pregnancy is the gold standard for measuring how well these agents work to preserve fertility, it is important that future studies take this into consideration.http://www.cochrane.org/reviews/en/ab001298.html
Main resultsThere is no evidence of benefit from the use of steroids, dextran or other pharmacological agents in any of the outcomes. The use of hyaluronic acid agents may decrease adhesion formation (OR 0.31, 95% CI 0.19 to 0.51) and prevent the deterioration of pre-existing adhesions (OR 0.28 (95% CI 0.12 to 0.66). There is insufficient evidence for the use of icodextrin 4% or SprayGel as adhesion-preventing agents. None of the studied agents has been shown to improve the pregnancy rate when used as an adjunct during pelvic surgery.
Authors' conclusionsThe current evidence for the use of fluid and pharmacological agents for the prevention of adhesions is limited. There is no evidence on any benefit for improving pregnancy outcomes when pharmacological and fluid agents are used as an adjunct during pelvic surgery.There is insufficient evidence for the use of the following agents: steroids, icodextrin 4%, SprayGel and dextran in improving adhesions following surgery.There is some evidence that hyaluronic acid agents may decrease the proportion of adhesions and prevent the deterioration of pre existing adhesions. However, due to the limited number of studies available, this evidence should be interpreted with caution and further studies are needed.
Full study
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001298/frame.html
and who do they as one of the references??????
METTLER!!!!
The use of fluids and pharmacological agents (medicinal drugs) to prevent the formation of adhesions (scar tissue) that may interfere with becoming pregnant after surgery of the female pelvis.
Adhesion formation is a condition in which bodily tissues that are normally separate grow together. This can occur after surgical procedures such as operations on the female pelvis to remove a cyst, treat endometriosis, remove a tubal pregnancy, or remove a fibroid (a benign tumour of the womb). This scar tissue can have serious effects on the woman's future fertility as it can lead to blockage of her tubes. Careful tissue handling at the time of surgery and control of the blood loss are important ways of reducing scar tissue, however, over the years other methods have been developed to minimise the risk of scar tissue formation. Surgeons have tried using different types of drugs or leaving different types of fluids inside the pelvis at the end of surgery to prevent tissue surfaces from sticking to each other. Fluids include dextran, icodextrin (Adept), SprayGel, and fluids containing the chemical hyaluronic acid (Intergel, auto-crosslinked hyaluronic acid, Sepracoat). Drugs that have been tried include steroids (anti-inflammatory drug), the anti-coagulant heparin, promethazine, and noxytioline.This review aimed to evaluate the role of these different agents in the prevention of adhesion formation. The results showed that there is currently insufficient evidence to recommend the use of steroids, icodextrin, SprayGel or dextran. The review did show that fluids that contained hyaluronic acid may help lower the chance of scar tissue forming; however, more studies are needed to confirm this. There are also some major safety issues concerning the use of one of these agents (Intergel), which has been withdrawn from the market due to reports of serious side effects such as allergic reactions and pain.A major problem with studies in this review is that most of them did not look at the rate of pregnancy following the use of these substances. Since the occurrence of pregnancy is the gold standard for measuring how well these agents work to preserve fertility, it is important that future studies take this into consideration.http://www.cochrane.org/reviews/en/ab001298.html
Main resultsThere is no evidence of benefit from the use of steroids, dextran or other pharmacological agents in any of the outcomes. The use of hyaluronic acid agents may decrease adhesion formation (OR 0.31, 95% CI 0.19 to 0.51) and prevent the deterioration of pre-existing adhesions (OR 0.28 (95% CI 0.12 to 0.66). There is insufficient evidence for the use of icodextrin 4% or SprayGel as adhesion-preventing agents. None of the studied agents has been shown to improve the pregnancy rate when used as an adjunct during pelvic surgery.
Authors' conclusionsThe current evidence for the use of fluid and pharmacological agents for the prevention of adhesions is limited. There is no evidence on any benefit for improving pregnancy outcomes when pharmacological and fluid agents are used as an adjunct during pelvic surgery.There is insufficient evidence for the use of the following agents: steroids, icodextrin 4%, SprayGel and dextran in improving adhesions following surgery.There is some evidence that hyaluronic acid agents may decrease the proportion of adhesions and prevent the deterioration of pre existing adhesions. However, due to the limited number of studies available, this evidence should be interpreted with caution and further studies are needed.
Full study
http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001298/frame.html
and who do they as one of the references??????
METTLER!!!!
Are you choosing between food, gas and meds?
We know that some of you are very hungery.
Here are some ways to get some food.
Bless you.
Food Assistance for Disaster Relief
FNS’s Food Distribution Division has the primary responsibility of supplying food to disaster relief organizations such as the Red Cross and the Salvation Army for mass feeding or household distribution. Disaster organizations request food and nutrition assistance through State agencies that run USDA’s nutrition assistance programs. State agencies notify USDA of the types and quantities of food that relief organizations need for emergency feeding operations.
Food Stamp Program
The Food Stamp Program helped put food on the table for some 10.3 million households and 23.9 million individuals each day in Fiscal Year 2004. It provides low-income households with coupons or electronic benefits they can use like cash at most grocery stores to ensure that they have access to a healthy diet.
National School Lunch Program (NSLP)
School districts and independent schools that choose to take part in the lunch program get cash subsidies and donated commodities from the USDA for each meal they serve. In return, they must serve lunches that meet Federal requirements, and they must offer free or reduced price lunches to eligible children. School food authorities can also be reimbursed for snacks served to children through age 18 in afterschool educational or enrichment programs.
School Breakfast Program (SBP)
The School Breakfast Program operates in the same manner as the National School Lunch Program. School districts and independent schools that choose to take part in the breakfast program receive cash subsidies from the USDA for each meal they serve. In return, they must serve breakfasts that meet Federal requirements, and they must offer free or reduced price breakfasts to eligible children.
Senior Farmers' Market Nutrition Program (SFMNP)
The Senior Farmers’ Market Nutrition Program awards grants to States, United States territories, and federally-recognized Indian tribal governments to provide low-income seniors with coupons that can be exchanged for eligible foods at farmers’ markets, roadside stands, and community supported agriculture programs.
Special Milk Program (SMP)
Participating schools and institutions receive reimbursement from the USDA for each half pint of milk served. They must operate their milk programs on a non-profit basis. They agree to use the Federal reimbursement to reduce the selling price of milk to all children.
State Processing Program
The State Processing Program allows States and eligible recipient agencies such as school districts to contract with commercial food processors to convert bulk or raw USDA commodities into more convenient ready-to-use end products. Most of the commodities processed through this program go to schools participating in the National School Lunch Program. Once the donated food is made available to States, the overall organization and administration of the State Processing Program become the responsibilities of the State agency.
Summer Food Service Program (SFSP)
SFSP is the single largest Federal resource available for local sponsors who want to combine a feeding program with a summer activity program. Children in your community do not need to go hungry this summer. During the school year, nutritious meals are available through the National School Lunch and School Breakfast Programs. But those programs end when school ends for the summer. The Summer Food Service Program helps fill the hunger gap.
Team Nutrition
Team Nutrition is a USDA initiative to provide training and technical assistance for foodservice, nutrition education for children and their caregivers, and school and community support for healthy eating and physical activity. Team Nutrition's Goal is to improve children's lifelong eating and physical activity habits by using the principles of the Dietary Guidelines for Americans and the Food Guide Pyramid.
The Emergency Food Assistance Program (TEFAP)
Under TEFAP, commodity foods are made available by the U.S. Department of Agriculture to States. States provide the food to local agencies that they have selected, usually food banks, which in turn, distribute the food to soup kitchens and food pantries that directly serve the public.
Women, Infants and Children (WIC)
The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the
http://www.fns.usda.gov/fns/services.htm
Here are some ways to get some food.
Bless you.
Food Assistance for Disaster Relief
FNS’s Food Distribution Division has the primary responsibility of supplying food to disaster relief organizations such as the Red Cross and the Salvation Army for mass feeding or household distribution. Disaster organizations request food and nutrition assistance through State agencies that run USDA’s nutrition assistance programs. State agencies notify USDA of the types and quantities of food that relief organizations need for emergency feeding operations.
Food Stamp Program
The Food Stamp Program helped put food on the table for some 10.3 million households and 23.9 million individuals each day in Fiscal Year 2004. It provides low-income households with coupons or electronic benefits they can use like cash at most grocery stores to ensure that they have access to a healthy diet.
National School Lunch Program (NSLP)
School districts and independent schools that choose to take part in the lunch program get cash subsidies and donated commodities from the USDA for each meal they serve. In return, they must serve lunches that meet Federal requirements, and they must offer free or reduced price lunches to eligible children. School food authorities can also be reimbursed for snacks served to children through age 18 in afterschool educational or enrichment programs.
School Breakfast Program (SBP)
The School Breakfast Program operates in the same manner as the National School Lunch Program. School districts and independent schools that choose to take part in the breakfast program receive cash subsidies from the USDA for each meal they serve. In return, they must serve breakfasts that meet Federal requirements, and they must offer free or reduced price breakfasts to eligible children.
Senior Farmers' Market Nutrition Program (SFMNP)
The Senior Farmers’ Market Nutrition Program awards grants to States, United States territories, and federally-recognized Indian tribal governments to provide low-income seniors with coupons that can be exchanged for eligible foods at farmers’ markets, roadside stands, and community supported agriculture programs.
Special Milk Program (SMP)
Participating schools and institutions receive reimbursement from the USDA for each half pint of milk served. They must operate their milk programs on a non-profit basis. They agree to use the Federal reimbursement to reduce the selling price of milk to all children.
State Processing Program
The State Processing Program allows States and eligible recipient agencies such as school districts to contract with commercial food processors to convert bulk or raw USDA commodities into more convenient ready-to-use end products. Most of the commodities processed through this program go to schools participating in the National School Lunch Program. Once the donated food is made available to States, the overall organization and administration of the State Processing Program become the responsibilities of the State agency.
Summer Food Service Program (SFSP)
SFSP is the single largest Federal resource available for local sponsors who want to combine a feeding program with a summer activity program. Children in your community do not need to go hungry this summer. During the school year, nutritious meals are available through the National School Lunch and School Breakfast Programs. But those programs end when school ends for the summer. The Summer Food Service Program helps fill the hunger gap.
Team Nutrition
Team Nutrition is a USDA initiative to provide training and technical assistance for foodservice, nutrition education for children and their caregivers, and school and community support for healthy eating and physical activity. Team Nutrition's Goal is to improve children's lifelong eating and physical activity habits by using the principles of the Dietary Guidelines for Americans and the Food Guide Pyramid.
The Emergency Food Assistance Program (TEFAP)
Under TEFAP, commodity foods are made available by the U.S. Department of Agriculture to States. States provide the food to local agencies that they have selected, usually food banks, which in turn, distribute the food to soup kitchens and food pantries that directly serve the public.
Women, Infants and Children (WIC)
The Special Supplemental Nutrition Program for Women, Infants, and Children - better known as the WIC Program - serves to safeguard the
http://www.fns.usda.gov/fns/services.htm
The defamation of service dogs.
Many disabled people rely on their service dogs to have any quality of life.
They are hard to come by and the more successful breeds are highly trainable and working is their joy.
Labs
German Shepard's
Doberman Pincher's.
Poodles
Too many to mention, even mutts!
We would just like to point out how a cheesy, ad campaing can compromise the service dogs ability to perform in public.
These dogs are also some of the greatest hero's of our country serving police and military.
Please stick up for service dogs as they will always be there for you.
Contact these people and tell them how you feel about their portrayal of service dogs.
Thank you for your message of concern about our current televisioncommercial that features a Doberman. We appreciate feedback from thepublic and we share it with our advertising agency.It is certainly not Alltel's intention to offend any particular breed ofdog and/or their owners. If this has happened we apologize. Our currenttelevision ad features a well-behaved and highly trained animal actorsimply playing a fictional role, as has been done in movies and ontelevision for years. We view this no differently than human actorsplaying roles opposite their true personality. Alltel continues to standbehind its current advertising campaign. Paul SageMarketing CommunicationsAlltel
http://us.f656.mail.yahoo.com/ym/Compose?To=corp.corporate.communications@alltel.com ; http://us.f656.mail.yahoo.com/ym/Compose?To=andrew.moreau@alltel.com ; http://us.f656.mail.yahoo.com/ym/Compose?To=lucie.r.pathmann@alltel.com , http://us.f656.mail.yahoo.com/ym/Compose?To=Paul.Sage@alltel.com
There are no bad dogs.....only bad owners!
Please visit Pathway to Hope's Prison Dog Program
http://www.picturetrail.com/gallery/view?p=999&gid=6681339&uid=989068
and
http://www.picturetrail.com/gallery/view?p=999&gid=1839198&uid=989068
They are hard to come by and the more successful breeds are highly trainable and working is their joy.
Labs
German Shepard's
Doberman Pincher's.
Poodles
Too many to mention, even mutts!
We would just like to point out how a cheesy, ad campaing can compromise the service dogs ability to perform in public.
These dogs are also some of the greatest hero's of our country serving police and military.
Please stick up for service dogs as they will always be there for you.
Contact these people and tell them how you feel about their portrayal of service dogs.
Thank you for your message of concern about our current televisioncommercial that features a Doberman. We appreciate feedback from thepublic and we share it with our advertising agency.It is certainly not Alltel's intention to offend any particular breed ofdog and/or their owners. If this has happened we apologize. Our currenttelevision ad features a well-behaved and highly trained animal actorsimply playing a fictional role, as has been done in movies and ontelevision for years. We view this no differently than human actorsplaying roles opposite their true personality. Alltel continues to standbehind its current advertising campaign. Paul SageMarketing CommunicationsAlltel
http://us.f656.mail.yahoo.com/ym/Compose?To=corp.corporate.communications@alltel.com ; http://us.f656.mail.yahoo.com/ym/Compose?To=andrew.moreau@alltel.com ; http://us.f656.mail.yahoo.com/ym/Compose?To=lucie.r.pathmann@alltel.com , http://us.f656.mail.yahoo.com/ym/Compose?To=Paul.Sage@alltel.com
There are no bad dogs.....only bad owners!
Please visit Pathway to Hope's Prison Dog Program
http://www.picturetrail.com/gallery/view?p=999&gid=6681339&uid=989068
and
http://www.picturetrail.com/gallery/view?p=999&gid=1839198&uid=989068
Thursday, June 12, 2008
Serious Illness? Learn How to Navigate the Health Care System
David Landay's Parental and Partner Losses Prompted His Consumer-Oriented Site
Hit Broadway producer David Landay watched cancer kill both his parents and HIV/AIDS snatch several close friends, and eventually his partner.
It seemed that dealing with death had become a frequent and unwanted aspect of his life.
"It was so common that my friend Sally came home and found this note on her refrigerator: 'Rich called. John is dead.' And it had just become that common," he said. "My partner David died, and after that, I decided I had to help full-time."
After navigating the difficult pathway of serious illness and the health care system, Landay wanted to help others do the same. So he launched a Web site, survivorshipatoz.org.
He developed the site to serve as a one-stop shop to help people dealing with cancer, AIDS or any other serious illness as they navigate the health care system.
"The idea would be to give people all the legal, financial and practical information they need; so that when you first got that diagnosis and all these questions come charging at you, the answers would all be there," said Landay, who produced the Broadway show "Woman of the Year" with Lauren Bacall, Raquel Welch and Debbie Reynolds.
He recognized that when people get hit with devastating news they are often are confused about what to do. They may not have enough savvy about the health care industry to debunk common myths.
"Health insurance is the most important asset you have, but one of the myths is you can't get it. Well, you still can get health insurance," Landay said.
Even with health coverage, meeting medical financial obligations can be difficult.
Read the rest and watch podcast. Click Here
Hit Broadway producer David Landay watched cancer kill both his parents and HIV/AIDS snatch several close friends, and eventually his partner.
It seemed that dealing with death had become a frequent and unwanted aspect of his life.
"It was so common that my friend Sally came home and found this note on her refrigerator: 'Rich called. John is dead.' And it had just become that common," he said. "My partner David died, and after that, I decided I had to help full-time."
After navigating the difficult pathway of serious illness and the health care system, Landay wanted to help others do the same. So he launched a Web site, survivorshipatoz.org.
He developed the site to serve as a one-stop shop to help people dealing with cancer, AIDS or any other serious illness as they navigate the health care system.
"The idea would be to give people all the legal, financial and practical information they need; so that when you first got that diagnosis and all these questions come charging at you, the answers would all be there," said Landay, who produced the Broadway show "Woman of the Year" with Lauren Bacall, Raquel Welch and Debbie Reynolds.
He recognized that when people get hit with devastating news they are often are confused about what to do. They may not have enough savvy about the health care industry to debunk common myths.
"Health insurance is the most important asset you have, but one of the myths is you can't get it. Well, you still can get health insurance," Landay said.
Even with health coverage, meeting medical financial obligations can be difficult.
Read the rest and watch podcast. Click Here
Saturday, June 07, 2008
Help advance pain care in our country
Take Action Now
Make Your Voice Heard!
Join forces with APF, other organizations and thousands of others across the United States who are committed to raising public awareness and promoting the best pain policy, legislation and practice.By uniting, mobilizing and leveraging our collective voices, we can improve pain management. It is not acceptable that 76 million Americans suffer pain and the majority do not receive appropriate care! Click here for more information on the latest National Pain Legislation and how you can Make Your Voice Heard!
There are FOUR critical actions you can take right now that will help advance pain care in our country.
Ask your Representative to co-sponsor the National Pain Care Policy Act of 2007 (HR 2994) - CLICK HERE.
The Veterans Pain Care Act, HR 6122, was introduced in the House of Representatives - CLICK HERE.
Request that your organization endorse the Consensus Statement for the National Pain Care Policy Act of 2007 - CLICK HERE.
Request that your organization endorse the Consensus Statement for the Military and Veterans Pain Care Acts - CLICK HERE.
From: The American Pain Foundation
Make Your Voice Heard!
Join forces with APF, other organizations and thousands of others across the United States who are committed to raising public awareness and promoting the best pain policy, legislation and practice.By uniting, mobilizing and leveraging our collective voices, we can improve pain management. It is not acceptable that 76 million Americans suffer pain and the majority do not receive appropriate care! Click here for more information on the latest National Pain Legislation and how you can Make Your Voice Heard!
There are FOUR critical actions you can take right now that will help advance pain care in our country.
Ask your Representative to co-sponsor the National Pain Care Policy Act of 2007 (HR 2994) - CLICK HERE.
The Veterans Pain Care Act, HR 6122, was introduced in the House of Representatives - CLICK HERE.
Request that your organization endorse the Consensus Statement for the National Pain Care Policy Act of 2007 - CLICK HERE.
Request that your organization endorse the Consensus Statement for the Military and Veterans Pain Care Acts - CLICK HERE.
From: The American Pain Foundation
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