A Review Study of Bladder Injury Inn Laparoscopy Assisted Vaginal Hysterectomy
Introduction
Bladder injury is very serious complication of lap assisted vaginal hysterectomy
Method of analysis retrospective analysis
Type of operative procedure laparoscopic assisted vaginal hysterectomy laparoscopic assisted vaginal hysterectomy performed using three port sign symptom of bladder injury During surgery balloon like distention of bladder catheter bag with gas or co2 discharge of clear fluid into the operative field haematuria management of bladder injury during surgery cause of bladder injury primary and secondary trocar perforation .hasson technique for open laparoscopy may reduce three type of injury .2nd and 3rd trocar should be inserted under vision previous surgery increase the risk of in advertent cystostomy by placing the bladder on traction close to umbilicus or because adhesion place it in the path of secondary trocar .in addition previous surgery can result in adhesion formation which obliterator the position of the bladder adhesion can for in the area of cervico-vaginal junction as result of previous cesarean section and extend the attachment of the bladder beyond lower uterine segment .other cause of mechanical injury .sharp scissors or blunt dissection of adhesion or seen near the dame of bladder may be adhesion from previous infection surgery relating to the bowel ,appendix or peritonitis .
Thermal injury
Excessive coagulation may be responsible for thermal bladder necrosis .use of unipolar cautry in proximity to the bladder surface should be avoided. Vesico vaginal fistula can occur following operative laparoscopy .it uterus is detached from bladder using unipolar or bipolar cautry excessive thermal coagulation may be responsible for thermal bladder necrosis .thermal necrosis may be some apparent only in post operative period when a vesico-vaginal fistula occurs –fistula can also occur if bladder is taken up when vagina is sutured from below .
Diagnosis
Injection of methylene blue via a bladder catheter will conform the diagnosis of vesico-vaginal fistula .I.V. P. Retrograde Cystography should also be done for through revaluation
Presentation of Bladder injury
To minimize bladder injury in patient with previous cesarean section Tran’s vaginal lateral intervention should be used to enter the anterior cul-de-sac during laparoscopic interfacial hysterectomy lateral window of vesico vaginal space aware opened first. Management of trocar veress needle injury .may be managed with folly catheter for one week with no subsequent complication .injury to bladder during laparoscopy assisted vaginal hysterectomy is small and loaded some distance away from trigone of bladder it can be retired laparoscopically two layer closer with delayed absorbable suture material and check that the bladder is water tight by injection 300 ml of methylene blue via the bladder catheter.
Incident of Bladder Injury 4-7 out of 1000
Sign to recognize bladder injury intraopeartive including following
1. CO2 catheter bag during insufflations
2. Bladder appears to be pushed by the accessory trocar as it is advanced through the abdominal well
3. Blood in Urine
4. Urine drainage from accessory trocar incision
5. Post operative urinary retention
6. Post operative signs of peritonitis
7. Leakage of Indigo carmine from the injured site
Prevention of Bladder Injury Insert is secondary Trocar under direct vision.
1. Separate bladder from lower uterine segment by using sharp dissection never dissect the bladder bluntly
2. Make sure the bladder is not inside the gain of laparoscopic stapling device before firing it.
3. Avoid excessive electro surgery around the bladder
Treatment
1. Repair is dependent upon whether injury is thermal or Mechanical
2. Whether injury is at the base of dome of bladder
3. Proximity of injury to trigone and ureteric opening
Treatment
If diagnosed at the time of surgery. Bladder injury at the dome can be repaired in a straight forward manner in two layer C PDS. Is layer should be continuous containing Muscular is Mucosal layers. Instillation of Indigo carmine dye assist identification of bladder boundaries laparoscopic repair of vesico vaginal fistula if presented after surgery is done after about 12 weeks. Vesico-vaginal space was developed both bladder vaginal were closed separately bladder with vicryl vagina with PDS. A peritoneal flash was used to separate vesico vaginal space and sutured with vicryl. Abdominal approach should be used for following indications.
1. Inadequate exposure because of high or retracted fistula in a narrow vagina.
2. Proximity of fistula to the ureter
3. Multiple fistula
4. Associated pelvic pathology bladder should be empted prior to surgery
New Technique
A new technique for dissecting the bladder laparoscopically was detected by James Cook University Hospital during laparoscopic assisted vaginal hysterectomy in department of minimal access surgery. 130 lavh were reviewed bladder was dissected laparoscopically a metal catheter was used to stretch Identification of bladder edge and a sponge forceps was inserted virginally to mark the site for anterior Colpotomy monopalar scissor were used to open virginal there was one bladder trauma 0.7% Which was recognized immediately and repaired with laparoscopy intra corporeal knot mean operating time was 198.7 minute recorded mean hospital stay was 2.7 days with range of 2 to 5 days dissection of bladder laparoscopically adds 5 to 10 minutes to operative time but significantly facilited identifying Appropriate plane it is an easy technique to learn and teach it is associated with minimal complication With no increase in incidence of bladder injury or dysfunction injury to bladder with laparoscopy Is rare said et al reported 1.6% incidence of serious urinary complications after major operative? Laparoscopy majority being bladder perforation or fistula there are four case of bladder injury in a series of 900 laparoscopic hysterectomy three of this for woman had under gone 2 or 3 c sections woman under going vaginal hysterectomy are more likely to sustain bladder injury if they have had previous c section. In this study these reporting 130 consecutive lavh in which bladder were dissected and ureteric vaginal pouch then opened laparoscopically. This technique was initially designed for woman who had previous c section in whom bladder was adherent and difficult to identify and dissect vaginally technique was later adopted in all cases because it appear ed to be easier and safer then vaginal route this technique was used in 130 lavh performed at james cook hospital technique was used in all patient in the same o t high pressure entry technique 25 mm hg using 3 port in addition to 10 mm umbilical port with 5 mm port inserted under direct vision in right and left iliac fosse later to deep epigastric vessels and are one inserted supra pubically. Bipolar diathermy and scissor were used to secure pedicles down to but not including uterine vessels both round ligaments were secured with bipolar diathermy peritoneum was dissected from one round ligament to other side. A metal catheter was then inserted in the bladder catheter was rotated so the tip was pointed up ward to stretch the bladder pillars bladder was dissected with monopolar scissor with catheter in place. A sponge forceps was then pushed in to vagina in to anterior fornix to stretch the vagina and mark the site for colpotomy monopolar scissor were used to open vagina and use of cutting diathermy and firing just prior to contact with vaginal tissue helped to achieve haemostatic without significant coagulation vagina opened in layers until sponge forceps was reached which was pushed in ward and blade opened widely to stretch the colpotomy procedure was completed vaginally. A Wertheim retractor was placed through to protect bladder uterine vessels were first secured with clamps and secured with vicryl followed by cardinal and utero sacral ligament and intra peritoneal drain as well as urinary catheter until following day result out of 130 patients 12 had C sections mean operative time was 98.7 minute. There was one bladder trauma which was recognized immediately and repair with laparoscopic intra corporeal knots. Cystoscopy was performed to ensure proper bladder repair and to exclude any other injuries. Patients has bladder catheter for 7 days at follow up 6 months post operatively she was well with no residual bladder dysfunction.
Discussion
It is difficult to detect the incidence of bladder injury with laparoscopic surgery in general LAVH specially GILMOUR et al (9) reported that major gynecological surgery the incident of bladder injury varied from 0.2 -19.5/ per one thousand with over all frequency of 2.6 per one thousand based on medlinereach for all reports between 1996 and 1998. The found a higher incidence of bladder injury when routine cystoscopic was perform with range from 0 to 29.2 and over all frequency of 10.4 per one thousand. Author commented that only 51.6% of bladder injury were identify and managed intraoperatively. Ostrzenski et al (10) reported the overall incidence of bladder
Study: Researchers Crack the Mystery of AIDS Immunity
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Bruce Walker, an AIDS researcher at Harvard University and Massachusetts General Hospital, has long been trying to understand why some people with HIV can remain untreated for decades and never progress to AIDS. On Nov. 4, Walker and colleagues published research that helps explain these HIV controllers: genetic variations that change key proteins in their immune systems.
The genetic variations change about a half-dozen amino acid building blocks; those variants make cells that are infected with HIV visible to the body's immune system and vulnerable to attack. NPR explained:
Five of the six variants are within a protein that controls how certain immune cells, called CD4s, display bits and pieces of viral protein on their outer shell — if they happen to be infected with a virus. HIV has a special affinity for infecting CD4 cells, and without constant antiviral treatment the virus slowly destroys the immune systems of most infected people.
But if a person has the newly discovered amino acid variants, his CD4 cells will be especially good at displaying pieces of HIV in a binding groove, or pocket of their outer coat. That enables killer cells, immune cells called CD8s, to target and kill the infected cells before they can spew forth more viruses.
For most people, the lack of these protective variants renders their HIV-infected cells invisible to their immune system.
Walker's team has also found these variants in people of European and African descent and in Hispanics. His team hopes their findings will help researchers figure out how to manipulate the immune response in people who do not have the benefit of the genetic variations. To learn more, see the study or further coverage on NPR. If you are interested in ugg boots sale,please visit our website:ugg boots sale
Study of Medical Courses From the Government Medical Colleges in India
Both in the diploma and degree level, there are various medical courses which a student can undertake to become a proficient doctor. Keeping this existing factor in mind, there are many colleges and institutes are offering courses and vocational trainings that are distinguishably oriented on the field of medicine. Even a dedicated student on this date can go for selecting the option of enrolling his name for such demanding courses on the Internet. Such an appreciable alternative based on the online factor are gaining importance and popularity across the globe. Even the government medical colleges in India are not lagging behind to provide its student a platform for learning these medical courses in an excellent paradigm. There are also some demanding courses offered in recognized institutes, after completion of which, an individual can work as a medical assistant, pharmacy technician and even dental assistant.
The Calicut Medical College is the medical institute situated at Kerala, founded in the year 1957. In this state, since its foundation, Calicut Medical College has grown itself to be a leading center of medical education. This reputed medical college is affiliated to the University of Calicut. B.Pharm, MBBS., MD in (Radio diagnosis, Biochemistry, Community Medicine, Pathology, Psychiatry, Pediatrics), B.Sc. in nursing, MS in (Anatomy, E.N.T., General Surgery) are the courses offered by this medical institute. Affiliated to AICTE, Armed Forces Medical College (AFMC), situated at Pune, Maharashtra was established in the year 1948. This medical college was formed by the honest amalgamation of the Army School of Hygiene, Army Medical Training Centre, the School of Blood Transfusion, the Central Military Pathology Laboratory and Army School of Radiology. Besides MBS and B.Sc. in nursing; a sincere student can also do PhD in (Physiology, Microbiology & Preventive and Social Medicine) from this recognized medical college. All India Institute of Medical Sciences (AIIMS), situated at Delhi/NCR, Delhi was established in 1952. Since then this prestigious medical college is offering excellent medical teaching to the students pursuing for either graduate or post graduate degree.
It is also found that students are keen to take admission in some of the most recognized medical colleges in Tamil Nadu where the educational culture is growing day by day. Christian Medical College (CMC-Vellore) situated at Vellore, Tamil Nadu is perhaps the most recognized medical institute where every dedicated student dream of seeking an admission. Christian Medical College (CMC-Vellore), of Vellore, Tamil Nadu offers excellent medical teaching for Diploma in Ophthalmology (D.O.), Bachelor of Pharmacy, Basic B.Sc. Nursing, M.Ch (Endocrine Surgery), Diploma in Clinical Pathology (D.C.P.), M.Ch. Cardio Thoracic Surgery, Diploma in Diabetology (D.Diab.), M.Ch. Neuro Surgery, Diploma in Medical Radio Diagnosis (D.M.R.D.), Diploma in Obstetrics and Gynaecology (D.G.O.), besides MBBS. Affiliated to All India Council for Technical Education (AICTE), Stanley Medical College (SMC), situated at Chennai, Tamil Nadu was established in the year 1938. These are the names of institutes that are included in the top 100 medical colleges in India.
Study Discovers Genetic Receptors Responsible For Hair Loss
Hair loss is natural. According to dermatologists, a healthy individual can lose about one hundred hair strands in just one day. However, hair loss becomes an alarming condition when a person loses more than the usual amount of hair that he sheds. Moreover, hair loss also becomes a problem if there is no observable hair growth or if hair loss occurs in the form of patches. When a hair loss problem occurs, immediate treatment may be vital. In relation to the continuous discovery and development of various hair loss treatments these days, a significant breakthrough has been made by an international team of researchers.
Culprit for the Hypotrichosis Simplex
Through a recent research made, researchers have successfully discovered a gene that is responsible for the development of the Hypotrichosis simplex. This is a hair loss condition that is hereditary. When afflicted with this condition, the patient will experience the onset of baldness at an early age - particularly even before he reaches his teenage years. As the patient grows older, the hair loss condition worsens. Eventually, the person afflicted with the disease can go bald and even lose his body hair.
Dr. Regina Betz, the project leader from Bonn's Institute of Human Genetics notes that their study is important primarily because it explores the mechanisms of hair growth. She points out that despite the fact that the occurrence of Hypotrichosis simplex is not very common, the findings of the study promote an overall understanding on the various factors that might contribute to the development of various forms of hair loss in general.
The study basically involved the analysis of the DNA samples of a Saudi-Arabian family, where four of the family members were diagnosed with Hypotrichosis simplex. The genetic material collected from the family provided the research project team with the key to understand the basic mechanisms of hair growth and the various factors that prompt the occurrence of hair loss conditions.
Based on the results of the study, the Hypotrichosis simplex is a genetic defect that is promoted by an improper growth of receptors that are vital for the natural hair growth process. When a person has this condition, the receptor structures on the surface of the hair follicles are not properly formed. The study notes that "when messengers from outside bind to these receptors (on the hair follicles), they trigger a chain reaction in the cell interior." These receptors are needed for the hair follicle to function normally.
Discovering New Medications for Hair Loss
Dr. Markus Nöthen, Chair of Genetic Medicine at Bonn University's Life & Brain Centre, further explains the importance of the recent study made. He notes that "the defective receptor structure falls into the category of what are known as G-protein-coupled receptors". These receptors are the usual "points of impact" for various forms of medications and treatments for hair loss. In addition to that, the study also showed that there is an "endogenous messenger" that is responsible for binding the hair follicle with the receptor.
According to Dr. Ivar von Kügelgen from Bonn's Institute of Pharmacology and Toxicology, the study has opened up new opportunities for various researches that are aimed at the development of "new active agents". He further notes that dermatologists and scientists can now specifically focus on looking for some substances that can be used in various hair loss therapies. These new medications can then be used to cure not just Hypotrichosis simplex, but other types of hair loss conditions as well.
RHIO Interoperability Case Study
The Philadelphia Health Information Exchange
Overview
The Philadelphia Health Information Exchange (PHIE), the nation's first diagnostic imaging exchange was launched in 2003. The network links healthcare providers in one of the largest and most demanding US healthcare markets encompassing some 4 million patients, 55 hospitals and 30 competing health systems.
In linking unaffiliated, even competing, medical facilities together, the PHIE enables the private, secure and seamless movement of patient digital medical records to speed and improve care across the region.
The exchange is based on Hx Technologies' patent-pending iHistory® platform. iHistory features a distributed ("federated" or "peer-to-peer") architecture, a design that is optimized for collaboration among competing enterprises and capable of interoperability with other regional exchanges and the anticipated nationwide health information network (NHIN).
The PHIE has focused initially on the sharing of diagnostic imaging data (both images and reports) with expansion to other clinical domains slated for later expansion.
Scope and Expansion
PHIE currently connects patient medical information across multiple disparate institutions, enabling interoperability across many different legacy systems. Initial participants include:
* The Hospital of the University of Pennsylvania
* Thomas Jefferson University Hospital
* Albert Einstein Medical Center
* Children's Hospital of Philadelphia
* Presbyterian Medical Center
* Pennsylvania Hospital
* UPHS Community Radiology
* Philadelphia Department of Public Health
Expansion to additional data providers and clinical users continues on a daily basis.
Usage
To date, the exchange enables physicians at participating facilities to securely access some 5 million imaging studies (which represents over 200 million total images) across 300,000 unique patients.
The PHIE effort has dual clinical and research tracks. On the clinical side, the exchange supports collaborations on patients shared between disparate organizations across departments including radiology, neurosurgery, fetal surgery, plastic surgery, neonatology, neurology, and obstetrics and gynecology. On the research side, investigators from participating sites and Hx Technologies are evaluating the impact of health information exchange along financial and clinical dimensions.
Recognition
Forrester Research recently completed a study of the Regional Health Information Organization (RHIO) market. Forrester defined a functioning RHIO as one that is that is in active clinical use across a broad cross-section of competing provider institutions. According to Forrester's study, PHIE is one of only 7 functioning health information exchanges in the US. Of the seven identified by Forrester, the Philadelphia Health Information Exchange was one of only two functioning exchanges operated by a for-profit venture and unique in targeting the largest regional population of all functioning exchanges.
The National Institute of Biomedical Imaging and Bioengineering (NIBIB) and the National Cancer Institute (NCI) continue to recognize the importance of the exchange through their continued financial support of some .3 million to date.
Autism Understanding Furthered By International Genetic Study
Autism understanding begins when a person realizes that autism is a disorder that affects people differently. Although autism affects the normal functioning of a person's perception, attention and thoughts, autism is not characterized by one type of perception, attention and thought. Instead, it covers a broad spectrum of disorders that may be mild or severe. Due to the fact that autism is such a complex disorder, medical research is still in the process of understanding how it develops and why it affects certain individuals.
One particular medical project with the aim to find better autism understanding by identifying the gene that causes autism, is the 5 year Autism Genome Project (AGP). So far, phase I of the AGP has identified a gene and parts of a chromosome to be linked with the occurrence of autism. The findings of this particular autism study was published online in the Nature Genetics February 18, 2007 issue.
The Autism Genome Project is a global research consortium that is funded by Autism Speaks and the National Institute of Health. Autism Speaks is a non-profit organization that is dedicated to raising the awareness of autism and raising funds to help research it.
The AGP involves more than 120 scientists from 50 institutions in 19 countries around the world. The researchers who have collaborated on the project combined their autism expertise, and shared all of the data and samples they had to help identify autism-related genes.
As was mentioned, phase I of this project began 5 years ago in 2002, and it allowed the team of medical experts to gain autism understanding by identifying a single specific gene known as neurexil 1, and part of chromosome 11 which could likely be the cause of autism in children. These findings are based on the largest autism genome scan that has ever been done.
Scientists have known for many years that autism is a genetic disorder, but only until the AGP have they been able to use special "gene chip" technology to search for genetic similarities in autistics. Genetic similarities were found in practically all of the autistic individuals within each of the twelve hundred families that that were made part of the project. The scientists also checked the DNA of each family to look for copy number variations that are believed might be connected to autism and similar disorders.
What the researches discovered in their study was that one particular gene known as neurexin 1 plays a significant role with glutamate; a neurotransmitter that has been formerly linked to autism. Researchers also uncovered an area of chromosome 11 that is suspected to contain a gene that may be involved in the occurrence of autism. However, this particular gene in chromosome 11 has yet to be identified which is required for further autism understanding.
Based on previous research, and the research that has been uncovered by the study so far, scientists speculate that there may be as many as 6 main genes and 30 additional genes linked to autism. However, these numbers are only theories, as scientists point out that the actual number of genes could exceed their theory. Nevertheless, despite the number of genes that may be involved, researchers admit that it is still far too early to dictate how these genes may be responsible for autism.
Currently, phase II of the Autism Genome Project has been announced. The promising discoveries found in phase I makes scientists hopeful that discovering the genes that cause autism will provide new steps toward autism understanding. With greater understanding, more effective methods of diagnosis, preventing and treating the disorder can be taken.