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Because of its complex subjectivity, pain is difficult to quantify, making an accurate assessment problematic. Is pain an important issue to the patient who is in the acute trauma/preoperative setting? As fanciful as that may seem, it must be emphasized that pain is a natural accompaniment of acute injury to tissues and is to be expected in the setting of acute trauma. In a study conducted at an accident and emergency room department of a university hospital in subSaharan Africa, 77% of patients who had preoperative analgesia considered the analgesic dosage inadequate, and 93% of those patients blamed this inadequacy of pain relief on inadequate analgesic prescription by their doctors. What should the attitude of the attending physician be regarding the specific management of pain in this scenario? Further measures include ensuring good patient positioning with the use of pillows and blankets in addition to the application of hot or cold compresses as needed. The perioperative period was uneventful, and the child (accompanied by his mother) was discharged home, fully awake and comfortable about 5 hours after the procedure with a prescription of oral paracetamol (acetaminophen). The mother gave him the prescribed analgesic, but the pain persisted, and the child had now become inconsolable and unable to go back to sleep, keeping the parents and the other siblings awake. Satisfactory analgesia should be feasible for every patient, irrespective of geographical location or level of resources. For the same type of surgical procedure, two similar individuals may perceive and experience pain very differently, and even for the same individual, the intensity of pain of a procedure may vary with time and activity. Strategies for ensuring effective postoperative analgesia Be proactive Effective postoperative pain management begins preoperatively. Patients are often very anxious and distressed by the hospital and procedure experience, and this distress may exacerbate pain postoperatively. Most patients recovering from anesthesia in the recovery room are comfortable because of the proactive and aggressive pain management by the anesthesia care provider. Unfortunately, when the patient is discharged, the intensity or continuity of pain care is disrupted. Use preemptive or preventive analgesia Preemptive analgesia implies that giving analgesia before the noxious stimulus is more effective than giving the same analgesia after the stimulus. One Pain Management in Ambulatory/Day Surgery should therefore aim to preempt or prevent pain if possible or proactively treat pain as early as possible. Psychological therapies include behavioral and cognitive coping strategies such as psychological support and reassurance, guided imagery, relaxation techniques, biofeedback, procedural and sensory information, and music therapy. Potent opioids, especially the long-acting ones like morphine and methadone, should preferably be avoided or used sparingly as postoperative analgesics for minor surgery because of their associated side effects, especially nausea and vomiting, respiratory depression, and sedation. However, if the severity of pain warrants the use of opioids, the shorter-acting agents such as fentanyl should preferably be used by careful titration to effect in the immediate postoperative period. This strategy will reduce intraoperative anesthetic requirements and facilitate earlier recovery and discharge. Tears at bedtime: a pitfall of extending paediatric day-case surgery without extending analgesia. Systemic analgesics may be administered by individuals who are not qualified to perform epidural or spinal blocks, and so they are often used in situations when an anesthesiologist is not available. They also are useful for patients in whom regional techniques are contraindicated. A systematic review of randomized trials of parenteral opioids for labor pain relief was able to show that satisfaction with pain relief provided by opioids during labor was low, and the analgesia from 123 What are the application routes for analgesia if needed? Pharmacological approaches to manage childbirth pain can be broadly classified as either systemic or regional. To achieve that outcome in the neonate, it is recommended to observe a certain time corridor for the application of pethidine to the parturient. Side effects are more likely to occur if delivery is between 1 and 4 hours after administration of pethidine. The intramuscular route is not recommended because it is not dependable-the rate of drug-absorption may vary. But ideally, naloxone-as most drugs in pain management, should be titrated intravenously to its effect (the cumulative dose would be, as for i. Milk concentrations low; plasma concentrations low-to-undetectable in infants; caution with chronic administration. Aspirin, due to its causal association with Reye syndrome, generally is not recommended in breastfeeding mothers. The use of pethidine (meperidine) in the perinatal period is increasingly controversial. Pethidine is metabolized to norpethidine, which is active and has a half-life of approximately 62 to 73 hours in newborns. Because of this prolonged half-life, neonatal depression after exposure to pethidine may be profound and prolonged. Postpartum anesthesia Nonopioid analgesics Non-opioid analgesics generally should be the first choice for pain management in breastfeeding postpartum women, as they do not affect maternal or infant alertness. Both pain and opioid analgesia can have a negative impact on breastfeeding outcomes; thus, mothers should be encouraged to control their pain with the lowest medication dose that is fully effective. However, when maternal pain 126 is adequately treated, breastfeeding outcomes improve. Katarina Jankovic breastfeeding because of negligible maternal plasma levels achieved. A randomized study that compared spinal anesthesia for elective cesarean with or without the use of postoperative extradural continuous bupivacaine found that the continuous group had lower pain scores and a higher volume of milk fed to their infants. Moreover, infant exposure can be further reduced if breastfeeding is avoided at times of peak drug concentration in milk. As breast milk has considerable nutritional, immunological, and other advantages over formula milk, the possible risks to the infant should always be carefully weighed on an individual basis against the benefits of continuing breastfeeding. Following a 2-mg intranasal dose, levels in milk were quite low, with a relative infant dose of about 0. This dose is probably too low to affect a breastfeeding infant, but this drug is a strong opioid, and some caution is recommended. While neuroleptics (promethazine) and antihistamines (hydroxyzine) are specifically indicated in nausea and vomiting, other drug classes have a direct effect on the distress of childbirth through their anxiolytic, sedative, and dissociative activity. Above all, a single small dose of benzodiazepines may be used (mainly midazolam or diazepam). Higher doses (10 mg hydrocodone) and frequent use may lead to some sedation in the infant. The Lancet deplored the use of this "unnatural novelty for natural labor"; however, royal sanction helped make anesthesia respectable in midwifery as well as surgery. The pudendal nerve block is useful for alleviating pain arising from vaginal and perineal distension during the second stage of labor. They are sometimes effective in early labor, but they usually need supplementation with a local anesthetic as labor progresses. This reduction is considered an advantage, since local anesthetics can produce unwanted motor block. Midwives can be trained to give low-dose intermittent top-ups as the mother requires. An electronic pump is required, and the patient must be thoroughly educated about using the device.

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The same cleaning checklist can be used to ensure all necessary deep cleaning tasks are completed before reopening the affected room/rooms to others. Keep the children and staff that were in the same room as the case-patient in the same room until their parents come to get them. Do not mix children and staff from the affected room with children or staff from non-affected rooms. This includes cleaning common areas of the facility prior to rooms where ill persons were present. Wait until the room or space is empty to vacuum, such as at night, for common spaces, or during the day for private rooms. These systems tend to provide better filtration capabilities and introduce outdoor air into the areas that they serve. If more than 7 days have passed since the person who is sick visited or used the facility, additional cleaning and disinfection is not necessary; the facility will only need your routine cleaning and disinfection to reopen. Closure may be recommended for the whole facility or just for one or more specific areas of the facility in which the infected person spent time. Facilities and health departments should take into consideration the needs and well-being of the staff and families served and decide what is best for the situation. The duration of the closure should be based on the estimated amount of time the facility and local health department think it will take to complete anticipated contact tracing and remediation activities in the facility, given the resources of the local health department and the facility. In response to a single case, a short-term closure of 3-5 days is generally sufficient. In terms of scope, the closure should be limited to the smallest unit where case(s) occurred and contacts were likely exposed. Depending on the size of the child care facility and the number of areas visited by the case-patient, it may be possible to close down only certain rooms or wings of a facility (i. Facility-wide closures shut down all rooms, or areas of the facility at the same time. The decision as to which approach is best is made in consultation with the local health department on a case-by-case basis with consideration of the distribution of known cases and contacts, extent of potential environmental contamination, and other factors, such as how quickly contacts can be traced and the facility can be cleaned and disinfected. Inform parents about the nature and extent of risk to their children and whether that risk indicates a need for quarantine and testing. In some cases, the proposed reopening date may need to be pushed back in response to logistics or investigation findings. Implement Enhanced Surveillance and Health Screening If not already in place, institute temperature and symptom screening for children and staff members. Early recognition of increased illness or absenteeism and limiting the number of potential contacts is key to controlling outbreaks. Refer to more detailed instructions in the sections on Health Screening at Entry (p. Pay special attention to areas where case(s) were identified and the environments they visited. Use the Outbreak Investigation and Control Checklist for Child Care Facilities (p. Monitor for New Cases in the Child Care Facility the child care facility should continue to actively monitor for new cases in children and staff for one month after the latest outbreak case was last present at the facility. This includes keeping and reviewing a line list of illnesses, monitoring absenteeism and reasons for absenteeism, and being in communication with the local health department when any concerns or questions arise. Temperature and symptom screening should continue in order to decrease the likelihood of new cases entering the facility. Staff should continue to be vigilant for children who become symptomatic while in child care and immediately isolate them. Staff should also be vigilant for children or staff who should be at home in isolation or quarantine who attempt to enter the facility too early. If additional cases are identified in the facility, the facility must notify the local health department so public health follow-up can be coordinated. Facilities should continue to add ill individuals to their line list, send ill individuals home as soon as possible to isolate, assist the local health department in identifying contacts of those new cases, and share line lists and contact information with the local health department to help control the outbreak. Facilities should review activities and exposures of the ill persons in the two weeks before they became ill to identify any links to other cases in the building through shared environments or staff. Any potential breakdowns in cleaning or management of ill children and staff should be rectified immediately to prevent further spread. At this point in the investigation, the facility should review their line list and present a final copy of the line list to the local health department. Any additional documentation requested from the local health department should be included. The local health department will then declare the outbreak over and close out the investigation. This is also an appropriate time to review what went well during the outbreak response and what could be improved upon should another outbreak occur in the facility. Facilities can consider conducting a "hot wash" or after-action review of the investigation with their local health department, which can be a beneficial exercise for identifying ways in which outbreak response could be improved. Certification is available for family child care providers who are not required to be licensed, but who wish to care for fewer than 3 children under 7 years of age. Families who receive a child care subsidy may select either certified or licensed child care programs. Child care facility: For purposes of an outbreak investigation, the child care facility is the business or operation where the outbreak is taking place. A child care facility may also be known as a child care program, child care center, day camp for children, and applies to both large care centers and smaller, in-home child care operations. Infectious period: the period of time during which an individual with a particular infection is capable of spreading the disease to other people. Isolation: Confinement of an ill person (or person with a positive test result but no symptoms) at home away from other people until they are completely recovered so they do not make other people sick. These centers are usually located somewhere other than a residence and may be small or large in size. Note: Certified child care programs are programs that provide care for 3 or fewer children under age 7 and undergo a voluntary certification process. Wisconsin is a home rule state and therefore, local health departments are the first avenue for investigating and responding to an outbreak. Quarantine may be shortened to 10 days after the date of last exposure, provided people still monitor for symptoms, wear a mask, and physical distance for the full 14 days. For persons who test positive but are asymptomatic, their infectious period is two days before the date their positive specimen was collected until 10 days after their positive specimen was collected. The confinement of well persons who were exposed to the virus through an ill person, positive person, or a person with a positive test result but no symptoms. In this way, if they develop symptoms during that time, they will not make other people sick. Close Contact An individual is considered a close contact if any of following is true. Report and inform Report the case and/or outbreak to: the Local Health Department. Participate in an initial conference call with the local health department to discuss the current situation and next steps. Notify all families of attendees and staff members of the situation and what they are to do. Follow local health department recommendations regarding exclusion (isolation/quarantine) to help contain spread. Consider whether it is necessary to quarantine entire groups or if temporary closure of affected areas is necessary, in consultation with the local health department. Assist the local health department with identifying persons who could have had close contact with the ill individual(s) using the Contact Tracing Checklist. Record names and contact information for close contacts in the Contact Tracing Tool.

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To accomplish this the autonomic innervation to the diseased system(s) as well as the lymphatic and surrounding musculoskeletal components should be addressed. The sympathetic innervation to all organs are housed in the prevertebral ganglion of the abdomen and in the sympathetic chain ganglion with sits anterior to the rib heads and transverse processes of the thoracic spine. All parasympathetic innervation comes from the vagus nerve that exits the jugular foramen with ganglion anterior to C1-2 and the pelvic splanchnics that arise from the sacrum. Addressing the various diaphragms of the body that may impede lymphatic vessels is a focused approach to improving lymphatic movement. Typical presentation includes postprandial abdominal pain, weight loss usually secondary food phobia, malnutrition, and possible abdominal bruit on physical exam. Then start with basic initial serum tests and the least invasive imaging in the diagnostic workup first. Treatment options include lifestyle modifications, medical therapies, surgical procedures, and alternative therapies. It benefits the primary care provider to be aware of special populations when evaluating patients for chronic abdominal pain complaints. Chronic Narcotic Users Review of past medical history such as co morbidities as well as medication use can also aid in gauging the cause of the abdominal pain. These changes described as opioid bowel dysfunction classically present as bloating, nausea, constipation, and abdominal pain. The danger with this phenomenon is providers tend to increase the dose of the patients narcotic medication. Chronic Abdominal Wall Pain: An Under-Recognized Diagnosis Leading to Unnecessary Testing. Its hallmark is abdominal pain or discomfort associated with a change in the consistency and/or frequency of bowel movements. Asia and Africa have similar rates to those in the United States, and the Western world in general. Physiological differences between men and women impact gastrointestinal transit time, visceral sensitivity, central nervous system processing, and specific effects of estrogen and progesterone on gut function. Research suggests that many patients with Irritable Bowel Syndrome have disorganized and appreciably more intense colonic contractions than normal controls. Patients with this disease appear to have a defect of visceral pain processing-although whether or not this is a true hypersensitivity or hyper-vigilance remains controversial. Colonic and rectal hypersensitivity (also called "visceral hyperalgesia") are also important factors in the causation of symptoms. Afferent nerves in the dorsal root ganglion synapse with neurons in the dorsal horn. Sensory pathway in Irritable Bowel Syndrome: an animated sequence (To view, click on the image above). In patients with rapid transit times, short or medium chain fatty acids can reach the right colon and cause diarrhea. In addition to pain and discomfort, altered bowel habits are common, including diarrhea, constipation, and diarrhea alternating with constipation. Patients also complain of bloating or abdominal distension, mucous in the stool, urgency, and a feeling of incomplete evacuation. Some patients describe frequent episodes, whereas others describe long symptom-free periods. Some patients have diarrhea-predominant symptomatology, others constipation-predominant, and still others have a combination of the two. Symptoms may vary from barely noticeable to debilitating, at times within the same patient. In some patients, stress or life crises may be associated with the onset of symptoms, which may then disappear when the stress dissipates. These may include headache, sleep disturbances, post-traumatic stress disorder, temporomandibular joint disorder, sicca syndrome, back/pelvic pain, myalgias, back pain, and chronic pelvic pain (Figure 8). The transverse portion crosses the abdominal cavity toward the spleen, then goes high up into the chest under the ribs, and turns downward at the splenic flexure. Continuing along the left side of the abdominal wall to the rim of the pelvis, the descending colon turns medially and inferiorly to form the S-shaped sigmoid (sigma-like) colon. These bacteria aid in decomposition of undigested food residue, unabsorbed carbohydrates, amino acids, cell debris, and dead bacteria through the process of segmentation and putrefaction. Short-chain fatty acids, formed by bacteria from unabsorbed complex carbohydrates, provide an energy source for the cells of the left colon. Maintenance of potassium balance is also assigned to the colon, where the epithelium absorbs and secretes potassium and bicarbonate. Sensory pathway in Irritable Bowel Syndrome, an animated sequence (To view, click on the image above). It is hypothesized that inflammatory cytokines may activate peripheral sensitization or hypermotility. This has raised questions regarding the use of the criteria in clinical research and further study is needed. The presence of "alarm symptoms" or "red flags" suggests more extensive evaluation for organic causes (Table 2). A colonoscopy should be performed in patients 50 years of age or older (a family history of colon cancer may warrant an earlier colonoscopy) and may detect organic disease in 1-2% of patients (Figure 12). Therapies may include fiber consumption for constipation, anti-diarrheals, smooth muscle relaxants for pain, and psychotropic agents for pain, diarrhea and depression. Patients with mild or infrequent symptoms may benefit from the establishment of a physician-patient relationship, patient education and reassurance, dietary modification, and simple measures such as fiber consumption. A positive, confident diagnosis, accompanied by a clear explanation of possible mechanisms and an honest account of probable disease course, can be critical in achieving desired management goals. In order to facilitate a positive relationship, it is important that the physician practice the following principles: Reassure the patient that they are not unusual Identify why the patient is currently presenting Obtain a history of referral experiences Examine patient fears or agendas Ascertain patient expectations of physician Determine patient willingness to aid in treatment Uncover the symptom most impacting quality of life and the specific treatment designed to improve management of that symptom In addition to addressing patient fears and concerns, physicians must evaluate whether or not the introduction of physician aids, such as dietitians, counselors, and support groups, may be of long-term assistance to the patient. Patients presented with detailed discussions about their diagnosis and treatment options have reduced symptom intensity and fewer return visits. The potential impact of stress in triggering or exacerbating symptoms, with reassurance that symptoms are not psychosomatic D. It has been demonstrated that patients with mild to moderate symptoms typically are most responsive to dietary modifications. However, the efficacy of bulking agents has not yet been clearly established-despite the fact that they are widely prescribed. Dietary modifications are the therapy of choice for patients with abdominal pain, diarrhea, flatulence and abdominal distension, with reported response rates of 50-70%. For each day of the week, patients should be encouraged to record the types of foods and beverages they have consumed, the number of bowel movements they have experienced, any pain they have experienced (on a scale form 1-10), their mood while eating, the time of day for each variable and any other relevant symptoms (Figure 14). Dairy products are the most common dietary triggers of gas, bloating, and occasional abdominal pain. While lactose intolerant patients should avoid consumption of milk and milk products (cheese, ice cream, and butter), it remains unclear whether or not a lactose-free diet demonstrates symptom resolution. Other research speculates that patients who are lactose intolerant may experience improvement not solely by abstaining from dairy, but by adhering to a fully exclusionary diet. In cases where milk products are reduced, care must be taken that enough calcium is added to the diet through either foods high in calcium, or a calcium supplement. The sugar sorbitol is only passively absorbed in the small intestine, and in clinical studies 10 g doses produced symptoms identical to lactose malabsorption in about half the patients tested. However, several other researchers argued this conclusion by suggesting that some patients do react adversely to sorbitol-fructose intake (especially those with diarrhea). High levels of sorbitol are found in apples, pears, cherries, plums, prunes, peaches and their juices.

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Although the early case-fatality rate appeared to be low, the rapid spread and ease of transmission of the virus, even by asymptomatic individuals, is causing global alarm: experts point out that although a virus may pose a low health threat at the individual level, if easily transmissible it can nonetheless pose a significant risk at the population level. Given its pandemic potential, careful surveillance of 2019-nCoV is critical to monitor its future host adaption, viral evolution, infectivity, transmissibility and pathogenicity (Huang, C. Diagnosis may be confirmed by chest radiography if there is evidence of infiltration consistent with pneumonia or respiratory distress syndrome. Neither virus isolation in cell cultures nor electron microscopy are sensitive enough for general diagnostic use and both methods are inconvenient. The virus remains detectable in respiratory secretions for more than one month in some patients, but after three weeks cannot be recovered for culture. However as the procedure for collecting these specimens is invasive, upper respiratory specimens are sometimes used instead (Chan, J. Differential Diagnosis Pneumonia of other viral or bacterial origin -especially Streptococcus pneumonia, Haemophilus influenzae, Moraxella catarrhalis, methicillin-resistant Staphylococcus aureus and Legionella spp. Other febrile viral diseases that should also be included in the differential diagnosis include seasonal and avian Influenza, Respiratory Syncytial Virus, Varicella Zoster Virus, human metapneumovirus and hantavirus. When appropriate, other epidemic or population-wide diseases may also need to be taken into consideration. Prevention Without effective drugs or vaccines against the infectious agent, physical interventions such as isolation and quarantine are the most effective means of controlling a coronaviral infections with epidemic potential (Jefferson, T. The success of these measures was demonstrated in Singapore, where application of infection control measures resulted in a decrease in the reproduction number (secondary infection rate) from 7 at week 1 to <1 after week 2 (Cleri, D. Hygienic measures are recommended to prevent the spread of disease in situations where individuals are in contact with patients or contaminated fomites. Washing hands with soap and water or with alcohol-based handrubs is effective for interrupting virus transmission. Personal protective equipment, including eye protection, is recommended for health care personnel, as well as surgical masks or N-95 disposable filtering respirators (Chan, J. Airborne precautions should be applied especially when performing aerosol-generating procedures such as intubation (Ben Embarek, P. The previous reporting requirements, formulated in 1951, required reporting for plague, cholera and yellow fever only, and the resulting delay in reporting cases early in the outbreak was likely to have contributed to its rapid spread (Enserink, M. Vaccines the successful containment of coronavirus epidemics in farm animals by vaccines, by either killed or attenuated virus, points to the potential success of vaccine programs. The S protein is currently considered to be one of the most promising targets for coronavirus vaccine development (Song, Z. The following table presents an up-to-date overview of the development of potential coronavirus vaccines. Supportive care is the mainstay of treatment for patients with severe disease (To, K. Initial efforts to treat the disease with broad-spectrum antibodies from human immune serum globulins were unsuccessful. Some nonspecific immunosuppressive treatments or broadspectrum antiviral agents, such as ribavirin, were of limited success (Lee, N. Some physicians preferred to delay administration of corticosteroids until the second week of infection in order to reduce side effects. In the case of ribavirin, 26 trials were inconclusive and four suggested potential harm. In the case of steroids, 25 studies were inconclusive and four indicated possible harm. They emphasized that clinical trials should be designed to validate a standard treatment protocol for possible future outbreaks, in order to standardize doses and timing of treatment and to facilitate data accrual and the monitoring of specific adverse effects and potential benefits of specific therapies (Stockman, L. Repurposing of known drugs with proven safety records is a faster and more efficient way of developing drugs in an outbreak situation, when time is of the essence. Ribavirin and interferon were the most widely used combination in observational studies, and may warrant further investigation (Momattin, H. The optimum dose was determined to be 1-3 mg/kg (or 160-240 mg/day) for a total accumulated dose of 1000-2000 mg. Based on this experience, routine use of corticosteroids is not recommended in patients with 2019-nCoV (Huang, C. Broad-Spectrum Antiviral Agents Ribavirin is a ribonucleoside analogue that is active against some coronaviruses, as well as respiratory syncytial virus and metapneumoviruses. Adverse events, including dose-dependent anemia, arrhythmia, chest pain and dizziness, are a significant concern with ribavirin (Cleri, D. With the possible exception of ribavirin, there is a lack of broad-spectrum antiviral agents. Unlike other infections agents (bacteria, fungi and parasites), viruses share extremely few common features that could be targeted by broad-spectrum agents. The development of broad-range agents requires a better understanding of pivotal virus-host interactions and the identification of targetable host cell proteins involved. Viral Enzyme Inhibitors the process of coronavirus replication is well understood. Several unique steps have been identified as potential targets for antiviral drugs. Nucleoside inhibitors might specifically inhibit viral replication without causing damage to the host cell. Targeted inhibitors of the serine proteases, which are required to activate the viral infectivity of some coronaviruses, may block the later stages of the viral life cycle (Kilianski, A. Following successful preclinical evaluation of lopinavir/ritonavir plus interferon-beta1b, in which significant reductions in mortality were obtained in a marmoset model, clinical evaluation of the combination was recommended (Chan, J. Since the combination of lopinavir and ritonavir was already available in the Wuhan, China hospital where early 2019-nCoV-infected patients were treated, a randomized controlled trial was quickly initiated to assess the efficacy and safety of the combination to treat this emerging coronavirus infection (Huang, C. Elements of the viral replication process have also been identified as potential therapeutic targets, including viral helicase, features of which are highly conserved among different coronaviruses (Adedeji, A. Other potential antiviral drug targets include virus assembly and exocytosis, which enables the release of virus from host cells. Despite a good understanding of viral targets and the identification of potential antiviral agents in vitro and in animal models, however, these findings have not translated into efficacy in humans (Zumla, A. Nine patients were given the combination therapy, while 13 patients were treated with corticosteroids alone. However, the incidence of transfers to the intensive care unit and need for intubation and mechanical ventilation were lower in the interferon/corticosteroid combination group (33. Most significantly, the incidence of mortality in the corticosteroid therapy group was 7. Furthermore, chest x-rays were normal within four days of initiating combination therapy, versus nine days in the corticosteroid monotherapy group (Loutfy, M. Because ribavirin decreases the release of proinflammatory cytokines in mice infected with the mouse hepatitis coronaviruses, it may also act as an immunomodulator (Peiris, J. Therefore some of its benefits may be due to its immunomodulatory activity (Mazzulli, T. A systematic review and meta-analysis of healthcare databases and so-called grey literature describing the use of convalescent plasma, serum or hyperimmune immunoglobulin derived from convalescent plasma to treat severe acute respiratory infections of viral origin has concluded that this approach is safe and may decrease the risk of mortality 22 (Mair-Jenkins, J. However, Saudi Arabian scientists reported that clinical trials evaluating this therapy would be challenging due to the limited availability of suitable donors, i. The antibody was tested in animal models, in which it protected against acute lung injury. Neutralization of Middle East respiratory syndrome coronavirus has also been achieved using monoclonal antibodies. Tables may also include drugs not covered in the preceding sections because their mechanism of action is unknown or not well characterized. For an overview of validated therapeutic targets for this indication, consult the targetscape below. The targetscape shows an overall cellular and molecular landscape or comprehensive network of connections among the current therapeutic targets for the treatment of the condition and their biological actions. Purple and pink text boxes indicate extracellular and intracellular effects, respectively.

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Prolonged ingestion of large doses of any one of the isolated B complex vitamins may result in high urinary losses of other B-vitamins and lead to deficiencies of these vitamins. It also functions with other substances to metabolis carbohydrates, fats, and protein. The main sources of this vitamin are green leafy vegetables, milk, cheese, wheat germ, egg, almonds, sunflower, seeds, citrus fruits and tomatoes. Its deficiency can cause a burning sensation in the legs, lips and tongue, oily skin, premature wrinkles on face and arm and eczema. It is contained in liver, fish, poultry, peanut, whole wheat,green leafy vegetables, dates, figs, prunes and tomato. A deficiency can lead to skin eruptions, frequent stools, mental depression, insomnia, chronic headaches, digestives disorders and anaemia. It helps in the absorption of fats and proteins, prevents nervous and skin disorders and protects against degenerative diseases. The main sources of this vitamin are yeast, wheat, bran, wheat germ, pulses, cereals, banana, walnuts, soyabeans, milk, egg, liver, meat and fresh vegetables. Deficiency can lead to dermatitis, conjuctivitis, anaemia, depression, skin disorders, nervousness, insomnia, migraine. Researches are on the threshold of a number of promising developments involving treatments of various ailments with this vitamin. They include hyperactivity in children, asthma, arthritis, kidney stones, blood clots in heart attack victims and nervous disorders. It is essential for the growth and division of all body cells for healing processes. Valuable sources of this vitamin are deep green leafy vegetables such as spinach, lettuce, brewers yeast, mushrooms, nuts,peanuts and liver. A deficiency can result in certain types of anaemia, serious skin disorders, loss of hair, impaired circulation, fatigue and mental depression. Some authorities believe that folic acid is contraindicated in leukemia and cancer. It stimulates the adrenal glands and increases the production of cortisone and other adrenal hormones. It also helps guard against most physical and mental stresses and toxins and increases vitality. The main sources of this vitamin are whole grain bread and cereals, green vegetables,peas, beans, peanuts and egg yolk. A deficiency can cause chronic fatigue, hypoglycemia, greying and loss of hair, mental depression, stomach disorders, blood and skin disorders. The minimum daily requirement of this vitamin has not been established, but is estimated to be between 30 and 50 mg a day. In some studies, 1,000 mg or more were given daily for six moths without side effects. It is useful in the treatment of insomnia, low blood pressure and hypoglycemia or low blood sugar. It is essential for proper functioning of the central nervous system, production and regeneration of red blood cells and proper utilisation of fat, carbohydrates and protein for body building. Valuable sources of this vitamin are kidney, liver, meat, milk, eggs, bananas and peanuts. Its deficiency can lead to certain types of anaemia, poor appetite and loss of energy and mental disorders. It promotes healing and serves as protection against all forms of stress and harmful effects of toxic chemicals. This vitamin is found in citrus fruits, berries, green and leafy vegetables, tomatoes, potatoes, sprouted bengal and green grams, A deficiency can cause scurvy marked by weakness, anaemia, bleeding gums and painful and swollen parts, slow healing of sores and wounds, premature ageing and lowered resistance to all infections. It prevents and cures colds and infections effectively, neutralises various toxins in the system, speeds healing processes in virtually all cases of ill. Linus Pauling, a world famous chemist and nutrition expert, " because vitamin C is one of the least toxic vitamins, it is very safe to use in high doses. It assists in the assimilation of calcium, phosphorus and other minerals from the digestive tract. This vitamin is found in the rays of the sun, fish,milk, eggs, butter and sprouted seeds. The recommended daily allowance of this vitamin for both adults and children is 400 to 500 international units. Therepeutically, upto 4,000 to 5,000 units a day for adult or half of this for children, is a safe dose, if taken for not longer than one month. It is beneficial in the treatment of muscular fatigue, constipation and nervousness. Signs of toxicity are unusual thirst, sore eyes, itching skin, vomiting, diarrhoea, urinary urgency, abnormal calcium deposits in blood vessel walls, liver, lungs, kidneys and stomach. It prevents unsaturated fatty acids, sex hormones and fat soluble vitamins from being destroyed in the body by oxygen. It is essential for the prevention of heart diseases, asthma, arthritis, and many other conditions. It is available in wheat or cereals germ, whole grain products, green leafy vegetables, milk, eggs, all whole, raw or sprouted seeds and nuts. Its deficiency can lead to sterility in men and repeated abortions in women, degenerative developments in the coronary system, strokes and heart disease. It is beneficial in the treatment of various forms of paralysis, diseases of the muscles, artheriosclerosic heart disease by diluting blood vessels. It also has a dramatic effect on the reproductive organs and prevents miscarriage, increases male and female fertility and helps to restore male potency. Its deficiency can lead to sufficient bile salts in the intestines, colitis, lowered vitality and premature ageing. In nutrition they are commonly referred to as mineral elements or inorganic nutrients. Like vitamins and amino acids, minerals are essential for regulating and building the trillions of living cells which make up the body. They must, therefore, be properly nourished with an adequate supply of all the essential minerals for the efficient functioning of the body. Minerals help maintain the volume of water necessary to life processes in the body. They help draw chemical substances into and out of the cells and they keep the blood and tissue fluid from becoming either too acidic or too alkaline. The importance of minerals, like vitamins, is illustrated by the fact that there are over 50,000 enzymes in the body which direct growth and energy and each enzyme has minerals and vitamins associated with it. Each of the essential food minerals does a specific job in the body and some of them do extra work, in teams, to keep body cells healthy. The mineral elements which are needed by the body in substantial amounts are calcium, phosphorous, iron, sulphur, magnesium, sodium, potassium and chlorine. In addition the body needs minute (trace) amounts of iodine, copper, cobalt, manganese, zinc, seleminum, silicon, flourine and some others. About 99 per cent of the quantity in the body is used for building strong bonesand teeth and the remaining one per cent is used by the blood, muscles and nerves. Without this mineral, the contractions of the heart would be faulty, the muscles would not contract properly to make the limbs move and blood would not clot. Calcium stimulates enzymes in the digestive process and coordinates the functions of all other minerals in the body. Calcium is found in milk and milk products, whole wheat, leafy vegetables such as lettuce, spinach, and cabbage, carrots, watercress, oranges, lemons, almonds, figs and walnuts. Deficiency may cause porous and fragile bones, tooth decay, heart palpitations, muscle cramps, insomnia and irritability. A large increase in the dietary supply of calcium is needed in tetany and when the bones are decalcified due to poor calcium absorption, as in rickets, oesteomalacia and the malabsorption syndrome. Liberal quantity of calcium is also necessary when excessive calcium has been lost from the body as in hyperparathyroidism or chronic renal disease. Phosphorous is found in abundance in cereals, pulses, nuts, egg yolk, fruit juices, milk and legumes.

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Decreased acid output, usually is the gastric transitional zone between corpus and antrum, give rise to gastric ulcer disease. If acid production is normal to high, the most severe inflammation usually is found in the distal stomach and proximal duodenum, giving rise to juxta-pyloric and duodenal ulcer disease. An increase in stimulated acid production predisposes to duodenal ulceration and decreased acid production predisposes to corpus gastritis or pangastritis which in turn predisposes to gastric ulceration, atrophic gastritis, and gastric carcinoma [22-23]. The intragastric distribution of gastritis is thought to be dependent on host genetic factors, bacterial virulence factors and environmental factors including age at onset of infection [23]. The humoral immune system has only marginal relevance for protective immunity in H. The key activator of the innate immune response is probably intracellular peptidoglycan [26]. Several cytokine genes have stable polymorphisms which are known to affect the level of cytokine production in response to H. This book chapter is open access distributed under the Creative Commons Attribution 4. Development of gastric metaplasia in the duodenum further allows bacterial colonization, thereby leading to duodenitis and epithelial damage. Gastric ulcers are associated with corpus gastritis, which is believed to damage the epithelium [24]. Eradication of the infection heals peptic ulcer disease, restores normal acid secretion and prevents ulcer relapse [25]. These cytokine polymorphisms may contribute to the risk of gastric adenocarcinoma, but their contribution to the risk of peptic ulceration is conflicting [28-29]. This impacts the mucosal protection by reducing the effectiveness of the mucusbicarbonate barrier; gastric acid, and possibly also pepsin, plausibly causing damage. Disease prevention may be possible by targeting the infection, either by eradication treatment or by preventing the establishment of the infection. Genta and Graham (1994), reported a sensitivity of 100% with biopsy specimens taken from angularis mucosa of the stomach. Histology provides useful information concerning the severity of gastritis and the possible presence of premalignant and malignant changes [34]. The latter method has the advantage of characterizing the immune response towards different bacterial antigens. Serologic methods have proven especially valuable in screening large number of individuals in epidemiologic studies [36]. These tests are relatively rapid and simple to perform, and much less expensive than tests requiring endoscopic biopsies. Serology tests may be more accurate than the biopsy based assays, which are local and subject to a variety of sampling errors [37]. Serological tests show positive result in a patient with gastric atrophy in whom the number of H. Major limitation of this test is that it has a limited role in confirming eradication of H. The argumentation has been further fueled by the suggested protective effect of the infection on esophageal adenocarcinoma. Nevertheless, general guidelines for treatment of the infection have been developed and continue to evolve [35, 14]. Patients presenting with persistent dyspepsia may also be offered eradication treatment, as it may lead to symptom improvement in a subset of patients [47-49]. The therapeutic regimens have been traditionally divided into mono, dual, triple and quadruple therapy depending on the number of antimicrobials. Ranitidine bismuth citrate combines antibacterial and antisecretory activities and can also be used. Dual therapy with omeprazole and amoxicillin for 2 weeks showed promising results initially, with eradication rates up to 80% [53]. Figures from Indian studies quote an eradication rate of 67% with triple therapy, with healing of ulcers in 93% and improvement in clinical symptoms and gastritis in patients with non-ulcer dyspepsia [54]. Some studies have also targeted highrisk population groups to study the effect of H. Antibiotic treatment has been reported to increase regression of cancer precursor lesions [60-61]. And despite low power and a lack of studies, there are many evidences that support the hypothesis that H. The appropriateness of such a large-scale and crude intervention has been questioned due to uncertain full spectrum of possible harmful consequences, for example development of antibiotic resistance [35,14,52]. However, reinfection may be more common in young children [57,56] and in high prevalence settings [58-59]. Post- eradication reinfection rates of about 20% have been reported in adults in high prevalence communities [58-59], thus being comparable to the incidence in childhood. These reported high reinfection rates speak against a significant role of protective immunity after therapeutic eradication and indicate that prevention of acquisition is needed to attain long-term absence of infection in some high-prevalence settings. An alternative approach could be to target the acquisition or persistence of the infection, while limiting the use of antimicrobials. A protective vaccine would also have to be administered at an early age before the acquisition of infection. At this age, an immature immune system may not respond sufficiently to immunization. Another approach could perhaps be a therapeutic vaccine that would circumvent problems with antibiotic resistance. There have been considerable efforts to develop safe and effective vaccines against H. Moreover, probiotics have been suggested to be capable of contributing to control H. Preventing establishment of infection by interfering with transmission is a strategy that has been used in public health interventions against a variety of infections. This can be partly explained by the fact that there is no apparent prevention strategy at present. The lack of thinkable interventions may be attributed to the seemingly multifaceted nature of H. There have also been attempts to detect a difference in the reinfection rates in children depending on whether the whole family unit received eradication therapy or not [55]. No significant difference was observed, however the authors acknowledged that the study was likely underpowered due to overall low re-infection rate. Antibiotic treatment is likely to play a central role in efforts to eliminate the infection. However, understanding and interfering with the acquisition or persistence of the infection by other means may become useful supplemental strategies. This is likely to be true in some low-income populations, where effective antibiotic regimens may be impaired by high cost, poor compliance, antibiotic resistance and high reinfection rates. The concomitant and sequential regimens are currently the best validated first-line therapeutic options. As efforts to improve empirical treatments continue, the fields of genotypic detection of H. The gastric transitional zones: neglected links between gastroduodenal pathology and helicobacter ecology. Peptic ulcer disease in a general adult population: the Kalixanda study: a random population-based study. Short-term mortality after perforated or bleeding peptic ulcer among elderly patients: a population-based cohort study. Current features of peptic ulcer disease in Finland: incidence of surgery, hospital admissions and mortality for the disease during the past twenty-five years. Declining incidence of peptic ulcer but not of its complications: a nation-wide study in the Netherlands. Recent trends in hospital admissions and mortality rates for peptic ulcer in Scotland 1982-2002. Non-steroidal anti-inflammatory drug associated upper gastrointestinal ulceration and complications. Role of Helicobacter pylori infection and non-steroidal anti-inflammatory drugs in peptic-ulcer disease: a meta-analysis. Eradication of Helicobacter pylori and risk of peptic ulcers in patients starting longterm treatment with non-steroidal anti-inflammatory drugs: a randomised trial.


  • Pancreatoblastoma
  • Ki-1cell lymphoma
  • Temtamy Shalash syndrome
  • Fetal prostaglandin syndrome
  • Macroepiphyseal dysplasia Mcalister Coe type
  • Protein S acquired deficiency
  • Erythrokeratodermia progressive symmetrica ichthyosis

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The romaine adds a vegetable element that is full of magnesium and other electrolytes, and prebiotic fibers. The addition of the Paleo Protein Powder means it will fill you up and be a complete meal or snack. Coconut butter and strawberries offer just a touch of sweetness with lots of prebiotics to feed the good gut bacteria. It also contains plenty of coconut which is full of lauric acid, a natural antimicrobial to kill bad yeast or bacteria in the gut. Before pan is warm, add coconut milk and gelatin and whisk well to combine until gelatin thickens. Remove pan from heat and add dates and allow to steep for about 3 minutes to soften dates. Transfer mixture into two small ramekins and chill in fridge for about 4 hours, until set. The addition of the Paleo Protein Powder makes this pudding full of healthy protein to keep you energized, and the coconut milk adds fat and antimicrobial properties. A warm soup like this in the morning will keep you full and satisfied before lunch. Coconut oil and scallions are natural anti-microbials, and the healthy fat from organic sausage will keep you full and your blood sugar stable for proper energy levels. Add sausage, breaking it up with a wooden spoon, and allow to cook until browned and cooked through. The touch of sweetness comes from banana which is full of minerals like magnesium. This recipe can be used for pancakes that are cooked on the stovetop or waffles cooked in a waffle iron. If mixture appear to be too dry, add water until it forms the consistency of a thick pancake batter. Feel free to keep the main ingredients and swap out the flavors as desired (for vanilla or berry, perhaps). Banana flour is high in minerals like magnesium and potassium, and the dates add sweetness along with prebiotic fiber. Zucchini offers minerals and fiber in this dish, and the onion and garlic provide sulfur to boost your detoxification abilities. Strain the bacon pieces with a slotted spoon and set aside, leaving grease in the pan. You can also take handfuls of the mixture and squeeze it over the sink to release the extra liquid. After about 10-15 minutes the turnips and zucchini will have browned and become crispy. Season with salt, pepper, and garlic powder, add the cooked bacon back to the pan, and give a final stir before serving. The coconut butter is full of medium chain triglycerides and caprylic acid to kill yeasts like candida. Non-starchy vegetables and hearty root vegetables are combined in this snack mix to tide you over until the next meal. They also provide gut-healthy prebiotic fibers and the coriander is a natural antibacterial to kill gut bugs. The oysters are full of healthy fats, plus vitamins A and D to reduce inflammation. This recipe calls for raw garlic and lemon juice for zing, plus their antimicrobial properties to restore healthy gut flora. The natural sweetness from the apples, date, and coconut butter shine through, while also providing minerals such as magnesium and prebiotic fiber. The coconut butter is also full of healthy medium chain triglycerides that are naturally antifungal to kill candida. The olive oil contains fatty acids to reduce inflammation, and the zucchini is full of calming magnesium. If mixture is too chunky, stream in a few tablespoons of olive oil while blender is running to thin. The onion, spinach, scallion, and garlic are full of sulfur to keep you detoxifying well, and the avocado is another fat source to keep your blood sugar stable. Allow to cook for about 30 minutes over medium heat, stirring frequently, until caramelized. Top potato with half of the caramelized onions and garlic, half of the spinach, two crumbled slices of bacon, and half of the avocado. Grass-fed bison and beef are a good source of iron, zinc, niacin, selenium, and vitamin B6. Iron is a critical mineral needed by the body to carry oxygen from the lungs to all tissues. Top each bowl with half of the ground meat, half of the avocado, and two of the thinly sliced radishes. The chicken is coated with coconut or cassava flour, both of which are full of prebiotic fibers to feed the good bacteria in the gut. Allow these to cook for approximately four minutes on each side until golden brown all cooked through. The celery and cucumber add electrolyte minerals to the salad, and the onion is a potent antimicrobial. Serve this cool, crunchy salad atop kelp noodles if you prefer for added crunch and extra iodine. Dark meat turkey is called for here because it contains healthy fats to balance blood sugar. This recipe pairs turkey with antibacterial spices like garlic, parsley, cilantro, cumin, and coriander. The cucumber and lettuce leaves add magnesium and potassium to round out this meal. Form the meat into 1-inch balls and place on a parchment paper-lined baking sheet and place in oven. These two ingredients are paired with antibacterial and antifungal spices, plus refreshing and magnesium-rich zucchini. Add onion and garlic to pan and cook for about 5 minutes or until tender, stirring occasionally. Add broccoli and bone broth and cook under tender but not mushy, approximately 4 minutes. In a small bowl, whisk together the stock, tapioca starch, white pepper and coconut aminos. Add the bok choy and mushrooms, stirring occasionally until almost cooked through but still slightly crunchy. The bone broth is an excellent source of gelatin, which seals up the gut lining, and the lard or bacon grease contain saturated fats to kill bad bacteria in the gut. Cover with a lid, and allow the bone broth to come to a simmer and cook until tender, approximately 10 minutes. Once preheated, add the lard or grease, as well as the meat, spices, and mushrooms. Asparagus, garlic, spinach and scallions are sources of sulfur for detox, and ginger is rich in antimicrobial oils to kill yeast and bacteria. Open parchments carefully over a plate and drizzle the sauce from the parchments over the fish and vegetables. The radishes are astringent which means they stimulate digestive juices to break down food and also kill bad gut bugs. The salmon and avocado contain healthy fats, and the spices are antimicrobial as well. As the cauliflower cooks, continue to baste the tops with the olive oil-lime mixture and then season with the spices. The basil contains healthy omega 3 fats, and the bacon contains monounsaturated fat - the heart-healthy kind that also happens to be good for the gut.

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As protection against accidental overflow of fluids into the suction regulator and hospital vacuum system, an overflow safety trap and/or filter should be used with the collection canister. In order to minimize flow rate reduction, all areas in the hospital, especially the operating room, should use large bore tubing and large inner diameter suction system fittings. Since some operative procedures yield large liquid volume in short periods of time, the suction system must be able to remove accumulated fluid quickly. Data shows that this important step (occluding the tubing or occluding at the vacuum regulator to set the regulator) is frequently unknown and/or not performed, resulting in inadvertent oversuctioning. Inadvertent oversuctioning may cause mucosal trauma, inflammatory response, bleeding, infection and, with endotracheal suctioning, traumatic atelectasis. In process analysis, the "occlude to set or check the vacuum pressure" is the problem step (often omitted). Despite considerable efforts by clinical leadership, this human behavioral element frequently persists and the maximum vacuum pressure setting is not properly set. New vacuum regulator technology has been developed to eliminate the problem step (occluding to set) and is available. Pushing in the pressure dial occludes the vacuum port so setting or checking maximum pressure is accomplished appropriately. In the early 1800s, researchers in Philadelphia and London used gastric tubes to wash out stomachs after poison ingestion. A century later, investigators reported successful treatment of intestinal obstruction (ileus) with gastric tubes. Instead, the end of the tube was placed below the patient so that a siphon effect would empty the stomach. In the 1920s and 1930s, Wangensteen and others determined this method of drainage was not adequate and that suction was necessary to empty the stomach. The early Wangensteen suction devices were complicated configurations that generated minimal vacuum of approximately 20 mmHg of continuous negative pressure. These devices were replaced by the electric thermotic suction devices and then vacuum regulators as more and more hospitals installed wall vacuum access. Now, intermittent suction units that provide true atmospheric pressure during the off cycle are the state-of-the-art devices. Gastric Tubes There are three basic types of gastric tubes in common use (Figure 24): 1. Large Ewald and Edlich tubes Salem Sump Tube this is a clear plastic, double-lumen tube, used most commonly for long-term nasogastric Figure 24 drainage. The larger (primary) lumen has holes at the tip and along the distal sides of the tube. The smaller lumen, the vent port - identified by a blue "pigtail" at the proximal end - is designed to allow air to enter the stomach during suction to modulate the effect of negative pressure to reduce the risk of the tube adhering to the stomach wall. Air can be injected into the pigtail (without disconnecting the primary lumen from suction) to move the tube away from the stomach wall or to dislodge particulate matter from the end of the tube and enhance drainage. The "pigtail" should never be tied off or clamped since tying off or clamping will eliminate its protective function. If gastric contents regurgitate through the vent port, the vent lumen will be partially or fully blocked. The collection bottle or the port itself may be too low relative to the distal end of the tube in the stomach, so that a siphon has been created. If raising the tube and collection bottle does not solve the problem, the tube may need irrigation. A short period of continuous low-pressure suction may be needed to empty the stomach and reduce the gastric pressure. Suppliers offer optional one-way valves or filters that allow air to enter the secondary lumen and prevent fluid reflux from escaping the tube and soiling the patient. Over the years, the double lumen tube has become the tube of choice for gastric drainage. The Levin tube now is used for short periods to assess gastric contents for the presence of blood or to decompress the stomach after resuscitation. Smaller-lumen tubes may be used for longer periods to provide tube feedings or medication. Because of their risk of adherence to the stomach wall with continuous suction, these single-lumen tubes are not regularly used for standard gastric drainage. The Principles of Vacuum and Clinical Application in the Hospital Environment - 2017 21 Ewald and Edlich Tubes the Ewald and Edlich tubes are large single-lumen tubes with multiple openings at the distal end. They are used for gastric lavage to remove ingested poison (particularly following overdose) or large blood clots resulting from gastric bleeding. Because of its large diameter, the tube allows rapid, high volume evacuation of gastric contents. The tube is inserted through the mouth into the esophagus and then into the stomach. It is only used long enough to remove specific gastric materials and/or to lavage the stomach. Insertion of Nasogastric Tubes Ohio Medical publishes a separate booklet, A Step by Step Guide for Nasogastric Tube Insertion. This photo guide illustrates the equipment needed for insertion of Salem sump and Levin tubes and the placement procedure. For a copy of the publication, either contact your Ohio Medical representative, or call Ohio Medical (866-549-6446 or 847-855-0500). Care of Nasogastric Tubes Nearly all nasogastric tubes are uncomfortable to patients. Placement of the tube through the nose requires breathing in and out of the mouth, which leads to mucosal drying. However, ongoing attention to oral hygiene can reduce the level of discomfort and protect delicate tissues. Frequent lubrication of the lips and nostrils with a water-soluble lubricant will also make the patient more comfortable. If not contraindicated, the patient can chew on ice chips to keep the mucosa moist. Periodic tube irrigation with fluid may be ordered by the physician or recommended by hospital policy and procedure. Fluid cannot safely be instilled into the tube until correct placement of the tube has been confirmed. Placement in the stomach can be confirmed by two procedures: the identification of gastric contents being removed through the tube and by instilling air into the tube with a syringe and listening for a gurgle over the epigastrium. The amount of irrigation fluid instilled and the amount removed should be noted for intake and output record-keeping. Patient monitoring should include assessment of the color, consistency and amount of drainage from the gastric tube. When bowel sounds return, indicating peristalsis, the tube can usually be removed since gastric secretions will no longer collect in the stomach. Monitoring stomach contents to determine gastric pH for patients with nasogastric tubes in place helps clinicians determine whether patients at risk for stress ulcers need pharmaceutical therapy or if prescribed therapy is working. Esophageal Tubes Esophageal tubes help control hemorrhage from esophageal or gastric varices. The Sengstaken-Blakemore, Linton and Minnesota tubes are characterized by balloons that can be inflated in the esophagus and/or stomach to compress the bleeding site. Multiple lumens at the proximal end of the tubes allow access to balloons, gastric irrigation and suction. After insertion, the balloons are carefully inflated: the inflation pressure of the balloons can be monitored with a manometer. If the balloons remain inflated for longer than 24 hours, the risk of pressure on the esophageal wall or gastric mucosa can cause necrosis and lead to additional bleeding or, in some cases, perforation. If a patient has esophageal varices, esophageal rupture is a possibility since varices weaken the esophageal wall. Nasoenteric (Intestinal) Tubes Nasoenteric or intestinal tubes used primarily for intestinal decompression help prevent nausea, vomiting and postoperative abdominal distention.


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The septum separates the respiratory and digestive tracts with the ventral portion developing into respiratory system and dorsal into gastrointestinal tract. By week 16 the esophagus has stratified squamous epithelium and swallow can appreciated. Failure of the tracheoesophageal septum development results in tracheoesophageal fistula and/or esophageal atresia. The liver develops from an endodermal outgrowth, hepatic diverticulum, at the cranioventral portion of the foregut. Hepatic cells (hepatoblasts), both hematopoietic and endothelial precursor cells, then migrate into the septum tansversum. The endothelial precursor cells, vitelline veins, are surrounded by hepatic cells forming the hepatic sinusoids. The hepatoblasts in mesenchyme closest to the portal vein form a bi-layered structure, the ductal plate. Abnormal development of intrahepatic bile ducts due to ductal plate malformations are likely the underlying cause of congenital hepatic fibrosis and cystic kidney disease as well as ciliopathies such as Joubert syndrome, Meckel-Gruber and Ivemark syndrome. Intrahepatic bile duct development starts at the hilum and progresses to the periphery of the liver. The common bile duct forms in an area of narrowing between the foregut and the hepatic diverticulum. At birth the most peripheral intrahepatic bile ducts are immature with persistence of ductal plate. Pancreas development begins during the 4th-5th weeks of gestation as distinct dorsal and ventral buds arising from the endoderm of the caudal foregut, the proximal duodenum. Rotation of the duodenum causes the ventral pancreatic bud to rotate clockwise to the left of the duodenum and brings it posterior and inferior to the dorsal pancreatic bud. The ventral bud forms the inferior part of the head of the pancreas and the uncinate process and the dorsal bud forms the superior part of the head, the body, and the tail of the pancreas. The main pancreatic duct (duct of Wirsung) which enters the duodenum at the major duodenal papilla (ampulla of Vater) is formed by the longer dorsal duct draining into the proximal ventral duct to form. If the proximal portion of the dorsal duct remains, it forms an accessory duct (duct of Santorini) that opens into a minor accessory papilla located about 2 cm above the main duct. The accessory duct opens into a minor papilla in 33% of people and ends blindly in 8% of people. Exocrine pancreatic development continues after birth with maturation of specific digestive enzymes. This is the most common variant (10%) and results from non-fusion of dorsal and ventral ducts during the second month of gestation. Midgut Formation (Slides 20-22) the distal duodenum, jejunum, ileum, cecum, appendix, ascending colon, and proximal 2/3 of transverse colon develop from the midgut, between the 6 and 10th weeks. The midgut loop herniates through the primitive umbilical ring during umbilical herniation at week 6. By ten weeks of development the abdomen has enlarged so that the entire length of the midgut can be accommodated. Following a 270 degree counterclockwise rotation around the superior mesenteric artery, the bowel returns to the abdominal cavity. The large intestine returns following the small intestine and does an additional 180 degree counterclockwise rotation. Clinical correlations include omphalocele which results from failure of the midgut loop to return to the abdomen. Some or all of the abdominal contents remain outside the abdominal wall covered with an outer amniotic and inner peritoneal sac. The diverticula often contain ectopic gastric, pancreatic, thyroid or endometrial tissue. Hindgut Formation (Slides 23-25) the distal 1/3 of the transverse colon, descending colon, sigmoid colon develop from the cranial end of the hindgut. The upper anal canal also develops from the terminal end of the hindgut with the urorectal septum dividing the upper th th anal canal and the urogenital sinus during the 6 week. By the 7 week, the urorectal septum fuses with the cloacal membrane, giving rise to the anal membrane and the urogenital membrane. The anal membrane ruptures during the 8th week allowing communication between the anal canal and the amniotic fluid. The superior 2/3 of the anal canal originates from hindgut and the inferior 1/3 is derived from proctodeum. Clinical correlation includes persistent cloaca resulting in fusion of rectum, vagina and urinary tract. The mesentery develops from the mesoderm and connects the primitive gut to the body wall. The ventral mesentery is present only between the liver and the stomach, and the liver and the duodenum. It forms the lesser omentum, between the liver and the stomach and duodenum, and the falciform ligament between the liver and the anterior body wall. During development some structures come to lie close to the posterior body wall and as the mesentery is absorbed the organ takes on a retroperitoneal position. Retroperitoneal organs include portion of the duodenum, the pancreas, the ascending and the descending colon. The neural crest cells arise between the neural plate and the epidermal ectoderm along the entire rostrocaudal extent of the embryo. Neural crest cells migrate during the 5th and 12th week of gestation, down to the anal canal. Cells from the sacral segment of neural crest cells migrate from the sacral segment to the hindgut during the 6th to 12th weeks. Interstitial cells of Cajal arise from the local gut mesenchyme and not from the neural crest cells. Short segment is more common accounting for 80% of cases with a 4:1 male to female ratio. The identified genes encode members of the Glial cell neurotrophic factor family, and are involved in either signaling pathways or are transcription factors. Ret stimulates enteric neural crest-derived cells to migrate, survive and differentiate. This is an indication of incomplete penetrance suggesting modifier genes, which have been identified. Gene Interactions have been identified in isolated Mennonite populations and in mouse models. Modifier genes are mutated gene that must be coupled with another mutation to result in or enhance the effect. Et-3 is a secreted protein expressed by gut mesenchyme that signals via Endothelin receptor B (Ednrb), which is expressed on migrating enteric neural crest cells. Homeoboxcontaining transcription factors (Hox genes) have been identified as critical genes in gut regionalization. These genes control cellular events, with different Hox genes found in different tissues (i. Sonic Hedgehog (Shh) is a transcription factor that controls endodermal-mesenchymal interactions. Blood Supply (Slide 43) Appropriate blood supply to the gastrointestinal tract and enteric organs is vital to health. Proximal Esophagus - Inferior Thyroid Artery Thoracic Esophagus - Terminal bronchial arteries Distal Esophagus - Left gastric and left phrenic arteries Stomach - Celiac artery Small intestine - Superior mesenteric artery Large intestine - Superior and Inferior mesenteric arteries sketchymedicine. Gastric Structure the stomach muscle layers include an outer longitudinal layer, a middle circular layer, and an inner oblique layer. The inner lining consists of four layers: the serosa, the muscularis, the submucosa, and the mucosa. The glands contain cells that produce digestive enzymes, hydrochloric acid, and mucus. Acid hypersecretion can also result in diarrhea and malabsorption of nutrients, particularly vitamin B12 and iron.

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For all patients, you will know if you are considered "leak free" when you receive a tray for lunch or dinner. If you receive a tray that does not appear to have the bariatric-appropriate items such as broth, sugar-free jell-o, sugar-free popsicles, etc. Length of Stay Most patients receiving an adjustable gastric band can expect an overnight hospital stay. For vertical sleeve gastrectomy, Roux-en-Y gastric bypass, or revision patients you can expect a two-night stay in the hospital. If you suffer with diabetes it is possible that one extra night in the hospital may be required. Taking Care of Yourself at Home When to Call Us after Surgery Your discharge instructions will contain a complete list of the things to call us about after surgery. If you are sent home with a drain, the nursing staff on the floor will give you detailed instructions on how to care for your drain at home. First, the drain site may have a little bit of redness to it where it goes into the abdominal wall. Should the redness increase in size, become more painful or appear to have pus at the site, please let us know. Should your drain contain any food particles from anything you have consumed, call us immediately. Should you notice fluid or food particles please do not eat or drink anything else and notify us at once. If you experience this more than five or six times per day, please notify our office. If you develop chest pain or shortness of breath, please do not call us- call 911. It is important you obtain 4x4 gauze pad, large band-aids and paper tape before going to the hospital. While the hospital and nursing staff will take care of your drain in the hospital you will be required to do this for yourself at home. The hospital will not send you home with enough supplies to care for your drain while you are at home. You should change your dressing at least two times per day and as needed if increased drainage is noticed. Your drain and staples will be removed at your first office visit after surgery which is generally 7 to 10 days after your surgery. You should have your first after-surgery appointment date and time set when your surgery is scheduled; however, if you do not, they will confirm it for you at the time of discharge from the hospital. Follow-Up Follow-up in our office is required one week (7 to 10 days), one month, three months, and one year after surgery. We also need to see you yearly for a total of five years after your surgical procedure. As a program, your health and success directly affect us and we really do strive to help you be the most successful patient you can be. When you come, you can expect to see not only a physician but also participate in a class especially designed for those who have had weight loss surgery. This class will update you on the latest and greatest in the bariatric literature specific to your postoperative period and help to keep you informed and knowledgeable about maintaining your health. As we must enter your health information to a database, all missed appointments will be contacted for rescheduling. Should you be unable to reschedule your appointment in a timely fashion, please ask the office staff at the time of the phone call to speak with one of the nurses so they can gather information about your current health. Reoperation In the event you are in need of an abdominal operation after bariatric surgery, you are more than welcome to see your hometown general surgeon for your issue(s). For your first abdominal reoperation after your bariatric surgery, we do recommend that you come back to us. Patients, especially those who lose an excessive amount of weight (more than 100 pounds) may develop hernias internally that are difficult to find and diagnose. As most general surgeons do not routinely care for the bariatric patient, they are often unaware that these hernias exist. By coming to us for the first surgery after your bariatric procedure, we will take the opportunity to look for these specific hernias and repair them at the time of your operation. Hopefully this will prevent an additional trip to the operating room in the future. General Medication Issues Upon discharge from the hospital you may take whole pills. Restrictive and malabsorptive procedures, such as Roux-en11 P a g e Y divided gastric bypass, can decrease the absorption of extended-release, delayed-release, enteric- or film- coated medication. If possible, immediate-release forms of medications should be substituted whenever possible. If given prescriptions for liquid forms of ulcer prevention medications or stool softeners please do not fill them. Psychiatric Medication Issues If not restarted in the hospital, please start taking your psychiatric medications the day you get home from surgery. Please do not spontaneously stop taking these medications without first consulting a physician. As depression is common after surgery, it is recommended that you stay on these medications for at least six months after your bariatric procedure. When you are ready to stop taking these medications, please consult your primary care physician for the most appropriate way to taper these drugs. If starting psychiatric medications for the first time after surgery, please be sure to ask your psychiatrist or primary care doctor for medications that do not promote weight gain. If your mental healthy symptoms recur, become worse, or you experience side effects from your psychiatric medication, please contact your providing prescriber for an adjustment. Ulcer Prevention Medication You will be provided, at the time of discharge, with a prescription for Pepcid. You do not need to fill the prescription for Pepcid if you already have one of these medications. We recommend that you stay on these medications for at least six months after surgery. Ulcers can be serious and difficult to treat, especially, in Roux-en-Y divided gastric bypass patients. Examples of these types of medications are aspirin, Ibuprofen, Excedrin, corticosteroids, oral bisphosphonates (such as Fosamax and Actonel), etc. Your primary care doctor will be sent a packet of information regarding acceptable medications to prescribe after surgery for pain. Should you change physicians, please notify our office and we will be happy to send a "Postoperative Physician" packet to your new primary care provider. At the time of your preoperative education class you will be provided a card noting this guideline. We believe, based on the current literature and our experience, that our recommendations are safe. Please do not follow information and/or instructions that you find in other literature or on the internet without consulting our program. The amount of food you can eat after surgery is restricted because a thin tube, or "sleeve," will be created from your natural stomach opening to the natural stomach outlet along the smaller, inner curvature of the stomach. Your current stomach is the size of a football, but after vertical sleeve gastrectomy surgery the new stomach will be about the size of a banana. The amount of food you can eat will be greatly reduced which helps you achieve significant weight loss. Some behaviors will need to be modified in order to achieve and maintain desired weight loss. These changes will include changing how you eat, how much you eat, and what you eat after weight loss surgery. This education booklet contains necessary information to help you achieve success. It is a good idea to read over this booklet several times before and after your surgery. There are six main groups of nutrients: protein, carbohydrates, fat, vitamins, minerals, and fluid. Protein, carbohydrates, and fats contribute calories (a measure of energy); whereas, vitamins, minerals, and water do not contribute calories to the diet. Understanding Protein, Carbohydrates, and Fat All foods can be categorized as a protein, carbohydrate, fat, or a combination of any three of these nutrients.