McGinty forced to guarantee patient's surgery
The West Australian Government is under pressure over revelations a 77-year-old Bibra Lake man has been forced to wait nine months for a simple bladder operation that should have been performed within 90 days.
Vitamins 'may up pregnancy risk'
High doses of vitamin supplements may raise the risk of pre-eclampsia in pregnant women rather than protecting against it, research suggests.
Basic social care 'must be free'
Ministers are urged to scrap means-testing and give all elderly people a minimum level of state-funded social care.
Medical Board pursues Patel accusations
The Queensland Medical Board is hoping for a directions hearing, in its case against disgraced surgeon Jayant Patel, in the Health Practitioners Tribunal next month.
Sleeping pill competition may spur ad war
NEW YORK (AP) - The maker of Ambien has begun a new ad campaign it hopes will reverse a sales slide triggered by reports that some patients couldn't recall driving or eating while sleepwalking when using the prescription sleep aid. The campaign Sanofi-Aventis SA launched Wednesday is likely the first salvo in what analysts predict will be a fierce advertising war in the market which has seen sales drop in the aftermath of the negative news. Sanofi's Ambien is expected to have a new competitor by this summer when Pfizer Inc. and partner Neurocrine Sciences Inc. are slated to debut a new pill
Carrying multiple babies risky for mom: study
NEW YORK (Reuters Health) - Women with multifetal pregnancies have a higher risk of pregnancy-related death than those with singleton pregnancies, according to a report in the journal Obstetrics and Gynecology.
No clear advice on elective C-sections
WASHINGTON (AP) - Women who want several children should avoid the new trend of purely elective Caesarean sections - planned surgical births when there's no clear medical need - government advisers said Wednesday. But for mothers-to-be who plan only one or two children, there's too little research to say definitively whether it's a good or bad idea.
U.S. Military Has New Online Mental Health Resource
Anonymous self-assessment program helps spot problems
Patient sues for possible disease exposure
ATLANTA (AP) - A woman has filed a lawsuit against Emory Healthcare after she underwent surgery there with instruments that had been exposed to a fatal disease similar to the human version of mad cow disease. Wayne Grant, an attorney for Tracy Price, said the lawsuit was filed Tuesday in DeKalb County. It accuses the university's healthcare system of medical malpractice, breach of fiduciary duty, reckless infliction of emotional distress and breach of informed consent. It seeks unspecified damages.
Pneumonia Vaccine Saving Lives
Study finds big drop in infection-linked death in hospitalized patients
Meeting To Determine Risks, Benefits Of Pre-Planned C-Sections Begins
FDA Approves Extended Dosing Of Aranesp
New Family Of Biodegradable Polymers Shows Promise For Intracellular Drug Delivery
Doctors Not Expected To Act Like ‘Saints' But Should Always Put Patients First, General Medical Council, UK
Health Protection Agency's Partner Launches Decontamination Product For Surgical Instruments, UK
Guidance On Internet Pharmacy Services By The Royal Pharmaceutical Society Of Great Britain
How Many Americans Have Multiple Sclerosis? No One Knows With Absolute Certainty
New York Times Letter To The Editor Responds To Opinion Piece On Physician-Patient Relationship
Growing Body Of Research Links Lead To Osteoporosis
Thursday, March 30, 2006
The New Medicine ...must see TV
Researchers, physicians, insurance companies and medical schools change the practice of medicine; a memorial to host Dana Reeve.
The New Medicine will premiere nationwide on PBS stations on Wednesday, March 29, 2006, from 9-11:00 EST. Please check your local listings for more broadcast information..
Watch a Video Preview
Program Description
Returning Human Touch to High-Tech Care
When Bill Moyers’ series, Healing and the Mind, premiered on PBS over 10 years ago, integrative medicine still lay on the fringes of the U.S. health care system. Today, it is booming. Even the most conservative health institutions are beginning to practice therapies once considered “new age”— acupuncture, visualization, self-hypnosis and mindfulness— alongside the more traditional drugs and surgery. Equally important is a new attitude that treats the patient as a whole person rather than a cog in an assembly line. The New Medicine, a two-hour documentary, hosted by Dana Reeve, takes viewers inside medical schools, healthcare clinics, research institutions and private practices to examine the rapidly expanding world of integrative medicine.
The producers of The New Medicine also created a related
The New Medicine Web site.
The New Medicine will premiere nationwide on PBS stations on Wednesday, March 29, 2006, from 9-11:00 EST. Please check your local listings for more broadcast information..
Watch a Video Preview
Program Description
Returning Human Touch to High-Tech Care
When Bill Moyers’ series, Healing and the Mind, premiered on PBS over 10 years ago, integrative medicine still lay on the fringes of the U.S. health care system. Today, it is booming. Even the most conservative health institutions are beginning to practice therapies once considered “new age”— acupuncture, visualization, self-hypnosis and mindfulness— alongside the more traditional drugs and surgery. Equally important is a new attitude that treats the patient as a whole person rather than a cog in an assembly line. The New Medicine, a two-hour documentary, hosted by Dana Reeve, takes viewers inside medical schools, healthcare clinics, research institutions and private practices to examine the rapidly expanding world of integrative medicine.
The producers of The New Medicine also created a related
The New Medicine Web site.
State Infertility Insurance Laws
If a state is not listed here, or if you have questions about insurance laws in your state, please call your state's Insurance Commissioner's office.
To learn about pending legislation in your state, please contact your State Representatives.
Click here to see ASRM publications and materials on Insurance Issues
Arkansas California Connecticut Hawaii Illinois MarylandMassachusetts Montana New Jersey New York OhioRhode Island Texas West Virginia
To learn about pending legislation in your state, please contact your State Representatives.
Click here to see ASRM publications and materials on Insurance Issues
Arkansas California Connecticut Hawaii Illinois MarylandMassachusetts Montana New Jersey New York OhioRhode Island Texas West Virginia
Gynecologic surgery and subsequent bowel obstruction
Diaa M. El-Mowafi Associate Professor, Obstetrics and GynaecologyDepartment of Obstetrics and Gynecology, Benha Faculty of MedicineLecturer and Researcher, Wayne State University, Detroit, Michigan, USAFellow, Geneva University, Switzerland
Michael P. DiamondProfessor and DirectorDivision of Reproductive Endocrinology and Infertility, Department of Obstetrics and GynecologyWayne State University, Detroit, Michigan, USA
Intestinal obstruction is a broad term, which entails cessation of the normal progression of the intestinal contents. Intestinal obstruction can be segregated into complete and incomplete blockage, and be due to mechanical or functional etiologies.
Mechanical obstruction is a term usually applied when there is an actual physical barrier blocking the intestinal lumen, such as bands of adhesion, strangulated hernias, and pressure from pelvic tumors. In contrast, adynamic ileus is used to describe disorders of propulsive motility of the bowel.
Mechanical Intestinal Obstruction
Intestinal obstruction is one of the more common and potentially fatal complications following gynecologic surgery. Forty years ago, mortality rate of 40% to 60% was not uncommon. Currently, the mortality rate has decreased but is still between 10% to 20% for all patients with obstruction of the small intestine.1
Adhesions, usually secondary to previous surgical procedures, are the most common cause of intestinal obstructions in the United States, and are responsible for 49% to 74% of small bowel obstruction in industrial countries.2 Menzies and Ellis3 reported that 93% of 210 patients who had previously undergone abdominal operations had substantial peritoneal adhesions at the time of reoperation. Gynecologic procedures, appendectomies, and other intestinal operations are the three most common type of surgical procedures performed before these occurrences.4,5 Lo et al,6 in 1966, reported a series in which 21% of patients with small bowel obstruction secondary to adhesions have had some form of gynecologic surgery. Melody,7 in 1957, reported that abdominal hysterectomy is the most common operation, which was associated with postoperative intestinal obstruction among 487 gynecological surgeries. In 1983, Ratcliff et al.,15 reviewed 59 cases of admitted women who underwent exploratory laparotomy for relief of small bowel obstruction. They found that 49 patients (83%) had previous abdominal surgery. Of these 49 patients, 38 (78%) had some type of obstetric or gynecologic abdominal procedure, of which 33 of the 49 (67%) had previously undergone a total abdominal hysterectomy.
In 1994, Monk et al.,8 reported that postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy was approximately 0.3%, increased to 2% to 3% among patients who underwent hysterectomy, and was as high as 5% if a radical hysterectomy was performed.
ADYNAMIC ILEUS
Some degree of adynamic ileus occurs after any intra-abdominal operation as well as in association with nearly all cases of intra-abdominal inflammation. The recovery of motor function of the intestines depends on many factors, including the length of the operation, the extent of handling of the bowel, the degree of chemical and bacterial peritonitis, and the underlying disease. After abdominal operations the patient usually feels hungry and passes flatus within the first three postoperative days. If the patient is not interested in eating, denies flatus and the abdomen is distended and has inaudible intestinal sounds, further diagnostic procedure may be called for. Radiography of adynamic ileus shows distention of both the small and large bowel, with scattered air-fluid levels.
The treatment consists of correction of any electrolyte imbalance, if present, as low serum potassium or sodium as well as hypomagnesemia and severe protein depletion can cause bowel atony. Ambulation, systemic and localized intestinal stimulation by rectal suppositories may be helpful. Otherwise, nasogastric intubation for decompression may be needed.1
PATHOPHYSIOLOGY OF INTESTINAL OBSTRUCTION
Obstruction of the small intestine causes collection of intestinal contents proximal to the obstruction leading to intestinal distention. Swallowed air, that represents over 70% of the air in the gastrointestinal tract, increases this distention. Because the veins and arteries enter the intestinal wall tangentially, the tension on them increases rapidly with distention. The veins, having the lower pressure, show the effect of the increase in tension first. As they are stretched, resistance in them increases, and flow slows down. Fluid rich in protein and salt begins to exude from the capillaries resulting in edema. Intraluminal fluid accumulation increases from both active secretion and decreased absorption. Subsequently, blood cells begin to escape from the capillaries, venous flow finally stops, and as arterial flow continues, blood accumulates in the wall and in the lumen of the bowel. If this process continues unabated gangrene occurs, intestinal integrity is lost and peritonitis quickly follows.1 Importantly, even in the absence of food and liquid ingestion, the volume within the gastrointestinal tract may continue to expand. The total volume of daily secretions into the normal gastrointestinal tract is estimated to be about 10 liters. As much as 7-8 liters of fluid can easily be sequestered in the bowel with intestinal obstruction.
Stagnant bowel contents in a distended loop of ileum show an increase in the number of bacteria. As long as the mucosa is intact and viable, the bacteria are harmless; however, increased intraluminal pressure for a sustained period will produce patchy areas of necrosis that allow some of the intestinal contents to escape into the peritoneal cavity. The main avenue of sepsis from intestinal obstruction is absorption from the peritoneal cavity and not the venous and lymphatic system.9
PATHOPHYSIOLOGY OF ADHESION FORMATION
Following peritoneal injury, the microvasculature beneath the mesothelium becomes disrupted. This is followed by extravasation of serum and cellular elements. Within 3 hours, this proteinaceous fluid coagulates, producing fibrinous bands between abutting surfaces.10 Twelve hours later; polymorphonuclear cells are entangled in fibrin strands, which are subsequently replaced with a macrophage infiltrate. By 48 hours after peritoneal injury, the wound surface is covered with a layer of macrophages.8 In normal peritoneal healing, the fibrinolytic system is triggered to lyse these fibrinous strands within 72 hours of the insult. Within the initial 5 days, re-epithelization of the peritoneal injury occurs. Interestingly, it appears that centripetal growth from the margin of peritoneal wounds contributes little to the healing p; the new mesothelium is derived from the metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells.11 Disruption of the existing equilibrium between fibrin deposition and fibrinolysis leads to persistence of the fibrinous strands, which then becomes infiltrated by proliferating fibrobiasts. Subsequently, vascularization and cellular ingrowth occur, and an adhesion is created.10
During mesothelial repair, macrophages and lymphocytes produce growth factors that modulate fibroblast proliferation and collagen synthesis, including platelet-derived growth factor, transforming growth factor-b , fibroblast growth factor, epidermal growth factor, interleukin-l, and tumor necrosis factor-a .12,13 Prostaglandins, particularly prostaglandin E2, are also involved in normal and abnormal mesothelial repair,14,15 most likely through a separate mechanism not related to fibroblast proliferation.16
Adequate blood supply is critical for normal fibrinolysis to occur. Peritoneal injurischemia interferes with fibrinolysis and leads to organization rather than resolution of the fibrin-cellular matrix.8 Ischemia may also induce adhesion formation by stimulating the growth of blood vessels form a non-ischemic to an ischemic site.17 Ischemia may result from excessive handling, crushing, ligating, suturing, cauterizing, or stripping of the peritoneum.
Foreign body reaction causes excessive formation of the fibrin coagulum that stimulates the development of adhesions. Common foreign bodies include sutures as well as cornstarch powder and lint from drapes, caps, gown, masks, and laparotomy pads. It is interesting that foreign bodies in the absence of peritoneal injury are an infrequent cause of adhesion formation.17
The presence of intraperitoneal blood has also been proposed to play a role in adhesion formation, although its actual contribution is not clear. However, free blood in the peritoneal cavity generally does not lead to adhesions, except in the presence of tissue ischemia.19
Infection may result in the development of adhesions by causing the release of proteolytic enzymes, which lead to ischemia and tissue damage, resulting in the formation of adhesions.5
In summary, ischemia seems to play the central role in adhesions formation and factors that compromise blood flow within the area of tissue injury lead to the development of adhesions. Thermal injury,20,21 infection,22 foreign body reaction,22,23 radiation induced endarteritis,24 and impairment of the fibrinolytic activity, all probably act via inducing ischemia to enhance adhesion formation. The thermal effect on adhesion formation called the question about optimal method to achieve hemostasis; is it cautery or sutures as both are incriminated in the etiology of development of adhesions.
DIAGNOSIS OF INTESTINAL OBSTRUCTION
The initial symptom of intestinal obstruction is sudden onset of crampy abdominal pain. This pain is intermittent, with intervals devoid of it which are longer than the periods of pain. The pain is classically periumbilical for a midgut obstruction. Vomiting may accompany the onset of pain with the possibility of recurrence if obstruction persists.
Inspection of the abdomen usually shows distention in persistent obstruction. Loops of intestine with visible peristalsis may be seen beneath the abdominal wall in the very thin patient. High-pitched, tinkling, or metallic intestinal sounds are characteristic of obstruction and occasionally can be heard without a stethoscope. These sounds represent the existence of the air-fluid interface. Motility with violent bursts of peristalsis occurs proximal to the obstruction. The duration of quiet intervals between bursts of peristalsis may suggest the level of obstruction; in high obstruction the time may be 3 to 5 minutes, whereas in low obstruction it may be 10 to 15 minutes.1 Palpation in the early stage of the disease may disclose no tenderness. As distention progresses, it is usual to find tenderness over the point of obstruction.
X-ray study demonstrating distended loop(s) of intestine with air-fluid levels, is suggestive of a mechanical obstruction, whereas grossly dilated loops of small bowel with gas in the colon is typically found is adynamic ileus.7 Computed tomography (CT) was used recently to diagnose postoperative intestinal obstruction due to adhesions.25 The CT findings that suggest strangulated obstruction are serrated beaks, mesenteric edema or vascular engorgement, and moderate to severe bowel wall thickening. In contrast, simple obstruction could be assumed when the beak is smooth, there are no mesenteric changes, and the bowel wall is normal or mildly thickened.
PERITONEAL CLOSURE AND ADHESIVE INTESTINAL OBSTRUCTION
Suturing the parietal peritoneum of the anterior abdominal wall at completion of gynecologic and obstetric surgery was always a tradition. Intuitive logic suggests that it will be of benefit to re-establish normal anatomical relationships and to prevent adhesion formation between the intestines and/or uterus and fascia. However, data supporting this hypothesis is lacking, and in fact it may be incorrect. Importantly, reperitonalization also places pelvic and abdominal contents within the abdominal cavity, and possibly makes fascial closure easier.
The microscopic cellular studies in animals have demonstrated that the broad peritoneal repairative process is different from that of the edge-to-edge skin cicatrization.26 When left undisturbed, peritoneal defects demonstrate mesothelial integrity (reperitonization) by 48 hours and complete indistinguishable healing i.e. without scaring can be achieved by 5 days.27, 28
Adhesions are caused by ischemia, inflammation, and infection rather than by open surfaces. Re-approximation of peritoneal edges or repair of defects via grafts, even with suture material considered to be minimally reactive, results in increased tissue ischemia and foreign-body tissue reaction, and may lead to increased adhesion formation at the site of reperitonization.29
Pietrantini and co-workers30 compared 127 patient in whom the peritoneum was left unsutured after cesarean section with another 121 patients in whom it had been closed with a continuous 000 polyglactin suture. There were no postoperative differences between the two groups regarding the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. They concluded that peritoneal closure at cesarean delivery provides no postoperative benefits, while unnecessarily lengthening surgical time, anesthesia exposure, and increasing patient costs. Finally, they advocated the elimination of closure of the parietal peritoneum from cesarean technique. However, they did actually evaluate the issue of the frequency of adhesion development as a function of peritoneal closure.
Hull and Yarner31 extended this modality to non-closure of the visceral and parietal peritoneum during lower segment cesarean section. In their randomized study on 113 patients, 59 patient were assigned to closure of both the visceral and parietal peritoneum with absorbable suture. The other 51 patients were left with no peritoneal closure. The incidence of postoperative fever, endometritis, or wound infection was not different between the two groups. The numbers of oral analgesic doses was significantly greater with closure of the peritoneum than without. The frequency with which postoperative lieus was diagnosed in each group was similar. Bowel stimulants were administered more frequently to the closure than to the non-closure patients. The average operating time was shorter for the open group than for the closure one.
Stricker et al32 reviewed 100 cases of female intestinal obstruction where they found that postoperative adhesions was the most common cause being present (59%). Fifty-six percent of those patients had a prior gynecologic surgery, most commonly abdominal hysterectomy. From 11 patients who had records from their previous operation, 9 patients had peritoneal closure; among these patients adhesions were found always to the site of reperitonization. In the 2 patients iwhom the peritoneum was left open, the adhesions causing the obstruction were found away form the site of reperitonization. In their study, Tulandi and others33 confirmed that non-closure of the parietal peritoneum after gynecologic surgery, as compared to closure using chromic cut gut suture did not increase adhesion formation found at second-look laparoscopy
Click Here to Continue
http://www.gfmer.ch/International_activities_En/El_Mowafi/Bowel_Obstruction.html
Michael P. DiamondProfessor and DirectorDivision of Reproductive Endocrinology and Infertility, Department of Obstetrics and GynecologyWayne State University, Detroit, Michigan, USA
Intestinal obstruction is a broad term, which entails cessation of the normal progression of the intestinal contents. Intestinal obstruction can be segregated into complete and incomplete blockage, and be due to mechanical or functional etiologies.
Mechanical obstruction is a term usually applied when there is an actual physical barrier blocking the intestinal lumen, such as bands of adhesion, strangulated hernias, and pressure from pelvic tumors. In contrast, adynamic ileus is used to describe disorders of propulsive motility of the bowel.
Mechanical Intestinal Obstruction
Intestinal obstruction is one of the more common and potentially fatal complications following gynecologic surgery. Forty years ago, mortality rate of 40% to 60% was not uncommon. Currently, the mortality rate has decreased but is still between 10% to 20% for all patients with obstruction of the small intestine.1
Adhesions, usually secondary to previous surgical procedures, are the most common cause of intestinal obstructions in the United States, and are responsible for 49% to 74% of small bowel obstruction in industrial countries.2 Menzies and Ellis3 reported that 93% of 210 patients who had previously undergone abdominal operations had substantial peritoneal adhesions at the time of reoperation. Gynecologic procedures, appendectomies, and other intestinal operations are the three most common type of surgical procedures performed before these occurrences.4,5 Lo et al,6 in 1966, reported a series in which 21% of patients with small bowel obstruction secondary to adhesions have had some form of gynecologic surgery. Melody,7 in 1957, reported that abdominal hysterectomy is the most common operation, which was associated with postoperative intestinal obstruction among 487 gynecological surgeries. In 1983, Ratcliff et al.,15 reviewed 59 cases of admitted women who underwent exploratory laparotomy for relief of small bowel obstruction. They found that 49 patients (83%) had previous abdominal surgery. Of these 49 patients, 38 (78%) had some type of obstetric or gynecologic abdominal procedure, of which 33 of the 49 (67%) had previously undergone a total abdominal hysterectomy.
In 1994, Monk et al.,8 reported that postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy was approximately 0.3%, increased to 2% to 3% among patients who underwent hysterectomy, and was as high as 5% if a radical hysterectomy was performed.
ADYNAMIC ILEUS
Some degree of adynamic ileus occurs after any intra-abdominal operation as well as in association with nearly all cases of intra-abdominal inflammation. The recovery of motor function of the intestines depends on many factors, including the length of the operation, the extent of handling of the bowel, the degree of chemical and bacterial peritonitis, and the underlying disease. After abdominal operations the patient usually feels hungry and passes flatus within the first three postoperative days. If the patient is not interested in eating, denies flatus and the abdomen is distended and has inaudible intestinal sounds, further diagnostic procedure may be called for. Radiography of adynamic ileus shows distention of both the small and large bowel, with scattered air-fluid levels.
The treatment consists of correction of any electrolyte imbalance, if present, as low serum potassium or sodium as well as hypomagnesemia and severe protein depletion can cause bowel atony. Ambulation, systemic and localized intestinal stimulation by rectal suppositories may be helpful. Otherwise, nasogastric intubation for decompression may be needed.1
PATHOPHYSIOLOGY OF INTESTINAL OBSTRUCTION
Obstruction of the small intestine causes collection of intestinal contents proximal to the obstruction leading to intestinal distention. Swallowed air, that represents over 70% of the air in the gastrointestinal tract, increases this distention. Because the veins and arteries enter the intestinal wall tangentially, the tension on them increases rapidly with distention. The veins, having the lower pressure, show the effect of the increase in tension first. As they are stretched, resistance in them increases, and flow slows down. Fluid rich in protein and salt begins to exude from the capillaries resulting in edema. Intraluminal fluid accumulation increases from both active secretion and decreased absorption. Subsequently, blood cells begin to escape from the capillaries, venous flow finally stops, and as arterial flow continues, blood accumulates in the wall and in the lumen of the bowel. If this process continues unabated gangrene occurs, intestinal integrity is lost and peritonitis quickly follows.1 Importantly, even in the absence of food and liquid ingestion, the volume within the gastrointestinal tract may continue to expand. The total volume of daily secretions into the normal gastrointestinal tract is estimated to be about 10 liters. As much as 7-8 liters of fluid can easily be sequestered in the bowel with intestinal obstruction.
Stagnant bowel contents in a distended loop of ileum show an increase in the number of bacteria. As long as the mucosa is intact and viable, the bacteria are harmless; however, increased intraluminal pressure for a sustained period will produce patchy areas of necrosis that allow some of the intestinal contents to escape into the peritoneal cavity. The main avenue of sepsis from intestinal obstruction is absorption from the peritoneal cavity and not the venous and lymphatic system.9
PATHOPHYSIOLOGY OF ADHESION FORMATION
Following peritoneal injury, the microvasculature beneath the mesothelium becomes disrupted. This is followed by extravasation of serum and cellular elements. Within 3 hours, this proteinaceous fluid coagulates, producing fibrinous bands between abutting surfaces.10 Twelve hours later; polymorphonuclear cells are entangled in fibrin strands, which are subsequently replaced with a macrophage infiltrate. By 48 hours after peritoneal injury, the wound surface is covered with a layer of macrophages.8 In normal peritoneal healing, the fibrinolytic system is triggered to lyse these fibrinous strands within 72 hours of the insult. Within the initial 5 days, re-epithelization of the peritoneal injury occurs. Interestingly, it appears that centripetal growth from the margin of peritoneal wounds contributes little to the healing p; the new mesothelium is derived from the metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells.11 Disruption of the existing equilibrium between fibrin deposition and fibrinolysis leads to persistence of the fibrinous strands, which then becomes infiltrated by proliferating fibrobiasts. Subsequently, vascularization and cellular ingrowth occur, and an adhesion is created.10
During mesothelial repair, macrophages and lymphocytes produce growth factors that modulate fibroblast proliferation and collagen synthesis, including platelet-derived growth factor, transforming growth factor-b , fibroblast growth factor, epidermal growth factor, interleukin-l, and tumor necrosis factor-a .12,13 Prostaglandins, particularly prostaglandin E2, are also involved in normal and abnormal mesothelial repair,14,15 most likely through a separate mechanism not related to fibroblast proliferation.16
Adequate blood supply is critical for normal fibrinolysis to occur. Peritoneal injurischemia interferes with fibrinolysis and leads to organization rather than resolution of the fibrin-cellular matrix.8 Ischemia may also induce adhesion formation by stimulating the growth of blood vessels form a non-ischemic to an ischemic site.17 Ischemia may result from excessive handling, crushing, ligating, suturing, cauterizing, or stripping of the peritoneum.
Foreign body reaction causes excessive formation of the fibrin coagulum that stimulates the development of adhesions. Common foreign bodies include sutures as well as cornstarch powder and lint from drapes, caps, gown, masks, and laparotomy pads. It is interesting that foreign bodies in the absence of peritoneal injury are an infrequent cause of adhesion formation.17
The presence of intraperitoneal blood has also been proposed to play a role in adhesion formation, although its actual contribution is not clear. However, free blood in the peritoneal cavity generally does not lead to adhesions, except in the presence of tissue ischemia.19
Infection may result in the development of adhesions by causing the release of proteolytic enzymes, which lead to ischemia and tissue damage, resulting in the formation of adhesions.5
In summary, ischemia seems to play the central role in adhesions formation and factors that compromise blood flow within the area of tissue injury lead to the development of adhesions. Thermal injury,20,21 infection,22 foreign body reaction,22,23 radiation induced endarteritis,24 and impairment of the fibrinolytic activity, all probably act via inducing ischemia to enhance adhesion formation. The thermal effect on adhesion formation called the question about optimal method to achieve hemostasis; is it cautery or sutures as both are incriminated in the etiology of development of adhesions.
DIAGNOSIS OF INTESTINAL OBSTRUCTION
The initial symptom of intestinal obstruction is sudden onset of crampy abdominal pain. This pain is intermittent, with intervals devoid of it which are longer than the periods of pain. The pain is classically periumbilical for a midgut obstruction. Vomiting may accompany the onset of pain with the possibility of recurrence if obstruction persists.
Inspection of the abdomen usually shows distention in persistent obstruction. Loops of intestine with visible peristalsis may be seen beneath the abdominal wall in the very thin patient. High-pitched, tinkling, or metallic intestinal sounds are characteristic of obstruction and occasionally can be heard without a stethoscope. These sounds represent the existence of the air-fluid interface. Motility with violent bursts of peristalsis occurs proximal to the obstruction. The duration of quiet intervals between bursts of peristalsis may suggest the level of obstruction; in high obstruction the time may be 3 to 5 minutes, whereas in low obstruction it may be 10 to 15 minutes.1 Palpation in the early stage of the disease may disclose no tenderness. As distention progresses, it is usual to find tenderness over the point of obstruction.
X-ray study demonstrating distended loop(s) of intestine with air-fluid levels, is suggestive of a mechanical obstruction, whereas grossly dilated loops of small bowel with gas in the colon is typically found is adynamic ileus.7 Computed tomography (CT) was used recently to diagnose postoperative intestinal obstruction due to adhesions.25 The CT findings that suggest strangulated obstruction are serrated beaks, mesenteric edema or vascular engorgement, and moderate to severe bowel wall thickening. In contrast, simple obstruction could be assumed when the beak is smooth, there are no mesenteric changes, and the bowel wall is normal or mildly thickened.
PERITONEAL CLOSURE AND ADHESIVE INTESTINAL OBSTRUCTION
Suturing the parietal peritoneum of the anterior abdominal wall at completion of gynecologic and obstetric surgery was always a tradition. Intuitive logic suggests that it will be of benefit to re-establish normal anatomical relationships and to prevent adhesion formation between the intestines and/or uterus and fascia. However, data supporting this hypothesis is lacking, and in fact it may be incorrect. Importantly, reperitonalization also places pelvic and abdominal contents within the abdominal cavity, and possibly makes fascial closure easier.
The microscopic cellular studies in animals have demonstrated that the broad peritoneal repairative process is different from that of the edge-to-edge skin cicatrization.26 When left undisturbed, peritoneal defects demonstrate mesothelial integrity (reperitonization) by 48 hours and complete indistinguishable healing i.e. without scaring can be achieved by 5 days.27, 28
Adhesions are caused by ischemia, inflammation, and infection rather than by open surfaces. Re-approximation of peritoneal edges or repair of defects via grafts, even with suture material considered to be minimally reactive, results in increased tissue ischemia and foreign-body tissue reaction, and may lead to increased adhesion formation at the site of reperitonization.29
Pietrantini and co-workers30 compared 127 patient in whom the peritoneum was left unsutured after cesarean section with another 121 patients in whom it had been closed with a continuous 000 polyglactin suture. There were no postoperative differences between the two groups regarding the incidence of wound infection, dehiscence, endometritis, ileus, and length of hospital stay. They concluded that peritoneal closure at cesarean delivery provides no postoperative benefits, while unnecessarily lengthening surgical time, anesthesia exposure, and increasing patient costs. Finally, they advocated the elimination of closure of the parietal peritoneum from cesarean technique. However, they did actually evaluate the issue of the frequency of adhesion development as a function of peritoneal closure.
Hull and Yarner31 extended this modality to non-closure of the visceral and parietal peritoneum during lower segment cesarean section. In their randomized study on 113 patients, 59 patient were assigned to closure of both the visceral and parietal peritoneum with absorbable suture. The other 51 patients were left with no peritoneal closure. The incidence of postoperative fever, endometritis, or wound infection was not different between the two groups. The numbers of oral analgesic doses was significantly greater with closure of the peritoneum than without. The frequency with which postoperative lieus was diagnosed in each group was similar. Bowel stimulants were administered more frequently to the closure than to the non-closure patients. The average operating time was shorter for the open group than for the closure one.
Stricker et al32 reviewed 100 cases of female intestinal obstruction where they found that postoperative adhesions was the most common cause being present (59%). Fifty-six percent of those patients had a prior gynecologic surgery, most commonly abdominal hysterectomy. From 11 patients who had records from their previous operation, 9 patients had peritoneal closure; among these patients adhesions were found always to the site of reperitonization. In the 2 patients iwhom the peritoneum was left open, the adhesions causing the obstruction were found away form the site of reperitonization. In their study, Tulandi and others33 confirmed that non-closure of the parietal peritoneum after gynecologic surgery, as compared to closure using chromic cut gut suture did not increase adhesion formation found at second-look laparoscopy
Click Here to Continue
http://www.gfmer.ch/International_activities_En/El_Mowafi/Bowel_Obstruction.html
DISCRIMINATION ACROSS THE NATION..
FOR CENTURIES WE HAVE READ AND HEARD FIRST HAND OF PEOPLE BEING DISCRIMINATED AGAINST.
THE AREAS OF DISCRIMINATION ARE SO BROAD , I THINK PEOPLE TEND TO NOT TAKE NOTICE TO CERTAIN GROUPS SO AFFECTED , THEY WOULD RATHER CRAWL IN A HOLE , SO TO SPEAK THAN DO SOMETHING ABOUT IT.
TAKE ARD FOR EXAMPLE, DO YOU FEEL THERE IS DISCRIMINATION TOWARDS THIS DISEASE?
SURE THERE IS.
WHEN DRS. IN EVERY FIELD CAN LOOK AT AN ARD SUFFERER AND REFER TO THEM AS EITHER BEING MENTALLY ILL, BECAUSE SURELY THIS DISEASE CANNOT CAUSE THESE ENORMOUS TYPES OF PAIN, SPASMS, NAUSEA, VOMITING, OBSTRUCTIONS,WEIGHT LOSS, WEIGHT GAIN, THIS IS DISCRIMINATION!
I CANNOT UNDERSTAND UNLESS THEY WALK A DAY IN OUR BODIES WHY THEY HAVE THE RIGHT TO JUDGE THIS PARTICULAR ILLNESS SO SEVERELY.
THEY DO NOT HAVE THAT RIGHT!! IT IS THE ARD SUFFERER THAT HAS TO TAKE A STAND TO THIS INJUSTICE.. IMMEDIATELY..
I REMEMBER WALKING MY HANDICAPPED CHILD THROUGH THE MALL, PEOPLE WOULD STARE, I WOULD BECOME ANGRY, I WOULD APPROACH THE PERSON AND DECLARE.. "IF YOU WISH TO STARE, PLEASE ASK ME WHAT YOUR QUESTION IS INSTEAD OF MAKING HIM AND I FEEL BAD .
SEE IT IS THROWN BACK TO THE PERSON WHO IS BEING DISCRIMINATED TOWARDS. THE FEELINGS OF DESPAIR, ISOLATION, SADNESS SET IN.
PEOPLE NEED TO BE ASKED WHY DO YOU LOOK? MAKE THEM BE ACCOUNTABLE FOR THE LACK OF INTELLIGENCE THEY ARE SHOWING ATT HIS PARTICULAR MOMENT!!!
I ONCE TRIED TO HIRE AN ATTORNEY TO PURSUE A LAW SUIT IN MY SON'S BEHALF AS HE HAD BEEN IN A NURSING HOME FOR CHILDREN FOR A SHORT PERIOD, AND IN THIS STAY SOMEONE WHILE HE WAS PLAYING ON THE FLOOR ROLLED OVER HIS HAND WITH A WHEEL CHAIR.
NOT ONLY WAS THIS HUSH , HUSH, WHEN I CAME DOWN TO RING HIM HOME FOR HIS WEEKEND VISIT HERE WAS A BRUISED MIDDLE FINGER THAT WAS NOT TENDED TO , BUT WHEN ASKED NOONE KNEW WHAT HAPPENED.
OF COURSE BEING THE GOOD PARENT I WAS , I TOOK HIM TO OUR FAMILY DR IMMEDIATELY.
EXRAYS WERE DONE, THE FINGER WAS SMASHED.
HERE IS WHAT THE LAWYERS SAID: "WHAT QUALITY OF LIFE DOES HE HAVE ANYWAY?" IF HE WERE AN ARTIST MAYBE WE COULD SUE.. BUT HE DOESN'T USE THE HAND THEREFORE WE HAVE NO CASE.
THEY GOT AWAY WITH THIS CRIME BECAUSE JOSHUA ONCE AGAIN WAS DISCRIMINATED AGAINST.
I REMEMBER THE HELPLESSNESS I FELT INSIDE, THE DEEP SADNESS I FELT FOR THIS CHILD, IF IT WEREN'T FOR ME HE WOULD HAVE BEEN CARTED OFF AND HID FROM SOCIETY.
WHEN HE WAS AN INFANT .. THEY SAID "TAKE HIM HOME AND LET HIM DIE". Do YOU FEEL THIS WAS DISCRIMINATION? I DO..
THEY MINIMIZED MY SON'S QUALITY OF LIFE IMMEDIATELY!!
TO THE YEAR HE PASSED, THE DRS WERE SAYING THERES NOTHING TO DO. SEE THEY HAD GIVEN UP, THE DRS , SO EASILY, BECAUSE IN THEIR MINDS HERES A CHILD WHO WOULD ALWAYS BE A CHILD, COST THE GOVERNMENT MASS QUANTITIES OF MONEY ETC... THEY WOULD FURTHER NO MORE TOHELP HIM STAY OUT OF PAIN, HAVE A MORE COMFORTABLE LIFE... ALL BECAUSE THEY DISCRIMINATED HIS QUALITY OF LIFE YOU SEE.
ARD IS DISCRIMINATED IN THIS MANNER.
IT IS IRONIC THE VARY SURGEONS THAT SEE THE ARD SUFFERER OPENED, THEY SEE AND FIX THE ULTIMATE DAMAGE THAT HAS ENSUED IN OUR BODIES, YET THEY ARE THE BIGGEST PART OF WHY WE ARE BEING DISCRIMINATED AGAINST!!!!
THEY ARE THE FIRST ONES TO SAY.... THIS COULD NOT BE THAT PAINFUL..
DISCRIMINATION ACROSS THE NATION I SAY!!!!!!!!!!!!
WHAT WILL IT TAKE FOR US TO BE HEARD????
WRITE YOUR LETTERS IF YOU ARE TOO SICK TO PROTEST ON GOVERNMENT STEPS... BE HEARD!!!!!!!! WE ARE THE ONLY ONES TO CHANGE THIS MIND SET OF OTHERS....
SOMETHING HAS BEEN LOST IN THIS DAY AND AGE, AS IN THE PAST GROUPS WOULD BE YELLING TO THE RAFTERS ABOUT THE DISCRIMINATION GOING ON ABOUT ARD!!!!
FOOD FOR THOUGHT...........SOT
THE AREAS OF DISCRIMINATION ARE SO BROAD , I THINK PEOPLE TEND TO NOT TAKE NOTICE TO CERTAIN GROUPS SO AFFECTED , THEY WOULD RATHER CRAWL IN A HOLE , SO TO SPEAK THAN DO SOMETHING ABOUT IT.
TAKE ARD FOR EXAMPLE, DO YOU FEEL THERE IS DISCRIMINATION TOWARDS THIS DISEASE?
SURE THERE IS.
WHEN DRS. IN EVERY FIELD CAN LOOK AT AN ARD SUFFERER AND REFER TO THEM AS EITHER BEING MENTALLY ILL, BECAUSE SURELY THIS DISEASE CANNOT CAUSE THESE ENORMOUS TYPES OF PAIN, SPASMS, NAUSEA, VOMITING, OBSTRUCTIONS,WEIGHT LOSS, WEIGHT GAIN, THIS IS DISCRIMINATION!
I CANNOT UNDERSTAND UNLESS THEY WALK A DAY IN OUR BODIES WHY THEY HAVE THE RIGHT TO JUDGE THIS PARTICULAR ILLNESS SO SEVERELY.
THEY DO NOT HAVE THAT RIGHT!! IT IS THE ARD SUFFERER THAT HAS TO TAKE A STAND TO THIS INJUSTICE.. IMMEDIATELY..
I REMEMBER WALKING MY HANDICAPPED CHILD THROUGH THE MALL, PEOPLE WOULD STARE, I WOULD BECOME ANGRY, I WOULD APPROACH THE PERSON AND DECLARE.. "IF YOU WISH TO STARE, PLEASE ASK ME WHAT YOUR QUESTION IS INSTEAD OF MAKING HIM AND I FEEL BAD .
SEE IT IS THROWN BACK TO THE PERSON WHO IS BEING DISCRIMINATED TOWARDS. THE FEELINGS OF DESPAIR, ISOLATION, SADNESS SET IN.
PEOPLE NEED TO BE ASKED WHY DO YOU LOOK? MAKE THEM BE ACCOUNTABLE FOR THE LACK OF INTELLIGENCE THEY ARE SHOWING ATT HIS PARTICULAR MOMENT!!!
I ONCE TRIED TO HIRE AN ATTORNEY TO PURSUE A LAW SUIT IN MY SON'S BEHALF AS HE HAD BEEN IN A NURSING HOME FOR CHILDREN FOR A SHORT PERIOD, AND IN THIS STAY SOMEONE WHILE HE WAS PLAYING ON THE FLOOR ROLLED OVER HIS HAND WITH A WHEEL CHAIR.
NOT ONLY WAS THIS HUSH , HUSH, WHEN I CAME DOWN TO RING HIM HOME FOR HIS WEEKEND VISIT HERE WAS A BRUISED MIDDLE FINGER THAT WAS NOT TENDED TO , BUT WHEN ASKED NOONE KNEW WHAT HAPPENED.
OF COURSE BEING THE GOOD PARENT I WAS , I TOOK HIM TO OUR FAMILY DR IMMEDIATELY.
EXRAYS WERE DONE, THE FINGER WAS SMASHED.
HERE IS WHAT THE LAWYERS SAID: "WHAT QUALITY OF LIFE DOES HE HAVE ANYWAY?" IF HE WERE AN ARTIST MAYBE WE COULD SUE.. BUT HE DOESN'T USE THE HAND THEREFORE WE HAVE NO CASE.
THEY GOT AWAY WITH THIS CRIME BECAUSE JOSHUA ONCE AGAIN WAS DISCRIMINATED AGAINST.
I REMEMBER THE HELPLESSNESS I FELT INSIDE, THE DEEP SADNESS I FELT FOR THIS CHILD, IF IT WEREN'T FOR ME HE WOULD HAVE BEEN CARTED OFF AND HID FROM SOCIETY.
WHEN HE WAS AN INFANT .. THEY SAID "TAKE HIM HOME AND LET HIM DIE". Do YOU FEEL THIS WAS DISCRIMINATION? I DO..
THEY MINIMIZED MY SON'S QUALITY OF LIFE IMMEDIATELY!!
TO THE YEAR HE PASSED, THE DRS WERE SAYING THERES NOTHING TO DO. SEE THEY HAD GIVEN UP, THE DRS , SO EASILY, BECAUSE IN THEIR MINDS HERES A CHILD WHO WOULD ALWAYS BE A CHILD, COST THE GOVERNMENT MASS QUANTITIES OF MONEY ETC... THEY WOULD FURTHER NO MORE TOHELP HIM STAY OUT OF PAIN, HAVE A MORE COMFORTABLE LIFE... ALL BECAUSE THEY DISCRIMINATED HIS QUALITY OF LIFE YOU SEE.
ARD IS DISCRIMINATED IN THIS MANNER.
IT IS IRONIC THE VARY SURGEONS THAT SEE THE ARD SUFFERER OPENED, THEY SEE AND FIX THE ULTIMATE DAMAGE THAT HAS ENSUED IN OUR BODIES, YET THEY ARE THE BIGGEST PART OF WHY WE ARE BEING DISCRIMINATED AGAINST!!!!
THEY ARE THE FIRST ONES TO SAY.... THIS COULD NOT BE THAT PAINFUL..
DISCRIMINATION ACROSS THE NATION I SAY!!!!!!!!!!!!
WHAT WILL IT TAKE FOR US TO BE HEARD????
WRITE YOUR LETTERS IF YOU ARE TOO SICK TO PROTEST ON GOVERNMENT STEPS... BE HEARD!!!!!!!! WE ARE THE ONLY ONES TO CHANGE THIS MIND SET OF OTHERS....
SOMETHING HAS BEEN LOST IN THIS DAY AND AGE, AS IN THE PAST GROUPS WOULD BE YELLING TO THE RAFTERS ABOUT THE DISCRIMINATION GOING ON ABOUT ARD!!!!
FOOD FOR THOUGHT...........SOT
Wednesday, March 29, 2006
The Dr. Kruschinski Dance : Now Playing ~ Emma Klinik
My friend the witchdoctor, he taught me what to sayMy friend the witchdoctor, he taught me what to doI know that you'll be mine when I say this to youooh eeh ooh ahah, ting tang wallawallabingbangooh eeh ooh ahah, ting tang wallawallabangbangooh eeh ooh ahah, ting tang wallawallabingbangooh eeh ooh ahah, ting tang wallawallabangbang
David Seville and the Chipmunks
Medical headlines ARDvark Blog
Mononucleosis increases risk of multiple sclerosis
NEW YORK (Reuters Health) - Infection with Epstein-Barr virus (EBV), resulting in infectious mononucleosis, which primarily effects adolescents and young adults, more than doubles the risk of developing multiple sclerosis (MS) later in life, results of a large review of studies suggest.
Couples must demand better deal for IVF
Infertile patients who spend thousands of pounds trying for a baby are risking exploitation, an expert has claimed
Chocolate may deepen depression
Chocoholics can happily eat chocolate for pleasure but for those who are stressed and clinically depressed, the high is short-lived and chocolate may even deepen the downer, a review shows.
Everyday Foods May Yield Medicinal Benefits
Chives, grape seeds and pine nut oil all show early promise, researchers say.
Most New Moms Exhausted: Study
C-sections, breast-feeding especially linked to postpartum woes.
Expert: Fertility industry needs regulation
Fertility treatment is a multi-billion dollar global industry that needs regulation to protect infertile couples and assure equal access to treatment, a leading American economist said.
New York Times Magazine Examines Issues Surrounding Induced Labor
Delay In Surgery Of Three Months Decreases Survival For Bladder Cancer Patients
Guidelines For Medication Withdrawal: When Or How To Stop
Physicians, Other Care Providers Rally To Protest Closing Of New Orleans' Charity Hospital
Disclosure Of Physicians' Financial Incentives May Increase Trust, Loyalty Among Their Patients
New Handbook Addresses Lesbian, Gay, Bisexual And Transgender Health Issues
High-dose Vitamin C As A Cancer Therapy
Should The US And New Zealand Ban Consumer Drug Ads?
Medical Device Related Adverse Incident Reports, UK
One In Seven Adults Uses The ER For Medical Care, USA
New Study Establishes Criteria To Detect Ovarian Cancer In Asymptomatic Postmenopausal Women
NEW YORK (Reuters Health) - Infection with Epstein-Barr virus (EBV), resulting in infectious mononucleosis, which primarily effects adolescents and young adults, more than doubles the risk of developing multiple sclerosis (MS) later in life, results of a large review of studies suggest.
Couples must demand better deal for IVF
Infertile patients who spend thousands of pounds trying for a baby are risking exploitation, an expert has claimed
Chocolate may deepen depression
Chocoholics can happily eat chocolate for pleasure but for those who are stressed and clinically depressed, the high is short-lived and chocolate may even deepen the downer, a review shows.
Everyday Foods May Yield Medicinal Benefits
Chives, grape seeds and pine nut oil all show early promise, researchers say.
Most New Moms Exhausted: Study
C-sections, breast-feeding especially linked to postpartum woes.
Expert: Fertility industry needs regulation
Fertility treatment is a multi-billion dollar global industry that needs regulation to protect infertile couples and assure equal access to treatment, a leading American economist said.
New York Times Magazine Examines Issues Surrounding Induced Labor
Delay In Surgery Of Three Months Decreases Survival For Bladder Cancer Patients
Guidelines For Medication Withdrawal: When Or How To Stop
Physicians, Other Care Providers Rally To Protest Closing Of New Orleans' Charity Hospital
Disclosure Of Physicians' Financial Incentives May Increase Trust, Loyalty Among Their Patients
New Handbook Addresses Lesbian, Gay, Bisexual And Transgender Health Issues
High-dose Vitamin C As A Cancer Therapy
Should The US And New Zealand Ban Consumer Drug Ads?
Medical Device Related Adverse Incident Reports, UK
One In Seven Adults Uses The ER For Medical Care, USA
New Study Establishes Criteria To Detect Ovarian Cancer In Asymptomatic Postmenopausal Women
Subscribe to:
Posts (Atom)