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E. Hauke, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Assistant Professor, Indiana University School of Medicine
A still later modification was proposed and used by Soave who stripped the mucosa from the distal aganglionic rectum and passed the normally innervated colon through the sleeve of dysfunctional rectum (an endorectal pull-through) relying on the normal portion to propel through the abnormal cuff womens health 2014 covers cheap 20mg female cialis with visa. Each of these procedures has been successful in overcoming the functional obstruction in the great majority of cases women's health center farmville va buy 10 mg female cialis with visa, but each has its own complications women's health issues in thrombosis and haemostasis purchase female cialis 20mg without a prescription. Common to each procedure is post-operative enterocolitis characterized by abdominal distention menstruation rituals ancient discount 10mg female cialis with mastercard, loose foul smelling stools, and vomiting. It occurs in a quarter to a third of cases and should be treated early and aggressively with rectal irrigations, anal dilatations and intravenous support as death may occur if it is neglected (3). Although fever and signs of infection may be present, stool cultures are often not helpful. The author routinely has parents or caregivers dilate the anus or irrigate the rectum postoperatively for several months to prevent enterocolitis. Most patients continue to improve bowel control for several years postoperatively (4). Incomplete emptying of the aganglionic portion of the pouch plagues some Duhamel patients. Patients with endorectal Soave procedures suffer from cuff abscesses and may require continued dilatations. Recently with the introduction of minimally invasive procedures involving laparoscopic dissection and various stapling devices, techniques have changed but the basic concepts for overcoming the non-relaxing, functionally obstructive distal colon are unchanged. The diagnosis is suggested in a term newborn who has emesis and abdominal distention early in the newborn period. Since a newborn usually passes his/her first meconium on the first day, the most suggestive symptom is the lack of meconium passage during the first day of life. Ninety-nine percent of normal newborn infants pass stool within the first 48 hours of life (5). A digital rectal examination is not helpful and may prevent an accurate contrast enema study, although a temperature probe may be gently inserted to prove anal patency. In the face of delayed meconium passage, vomiting and abdominal distention, an abdominal series should be obtained. In congenital megacolon, intestinal dilatation is usually present with a gasless rectum. A hand injected contrast enema should be obtained to outline the rectum and sigmoid colon. Particular attention should be directed at not overfilling the intestines, thus obscuring the transition zone. Although the gold standard of diagnosis is the histological absence of ganglion cells and hypertrophied autonomic nerves, the typical radiographic transition zone between the proximal dilated and distally narrowed colon is sufficient evidence for the diagnosis in the face of supportive presence of delayed meconium passage, vomiting, and distention. Histochemical patterns with special staining techniques have also been correlated with ganglion cell absence. Page - 360 Occasionally an older child presents with a history of long standing constipation requiring enemas and other attentive measures directed at producing defecation. In such cases the diagnosis is made by contrast enema as the transition zone is usually easily demonstrated. Contrast enemas in infants less than two months old may be non-diagnostic in over 20% of cases (6). In these instances when clinical and radiographic findings are unable to make a definitive diagnosis, a rectal biopsy becomes necessary. Although ganglion cells are more sparse, the associated presence of hypertrophied nerve fibers is diagnostic. The normal physiologic pressure in the anal canal during defecation involves a decrease in internal sphincter pressure (relaxation) with rectal distention, thus allowing passage of the fecal bolus. The most frequently involved areas of aganglionosis are the rectum and sigmoid, with decreasing incidence progressing cephalad. Total aganglionosis of the colon is a rarity, and small bowel involvement is even less common. There is a familial inheritance factor greatest among siblings but less common among children of parents with the disease. It is one of the most common causes of infant intestinal obstruction and is exceeded only by intestinal atresia, malrotation and meconium ileus (in Caucasians). True/False: In a child over a year of age with a radiographic transition zone, a rectal biopsy is required for a definitive diagnosis? The Treatment and Postoperative Complications of Congenital Megacolon: A 25 Year Follow Up.
After completing a full physical examination menstruation running buy female cialis 20mg without prescription, her physician orders an x-ray of the chest women's health clinic grand rapids discount 10 mg female cialis amex, which shows enlarged hilar nodes bilaterally as well as lung nodules pregnancy 7 weeks 1 day generic female cialis 20 mg on-line. A 64-year-old man with sepsis has an increased peripheral metabolic rate and hypercapnia women's health issues in bangladesh order female cialis 20mg overnight delivery. With regard to carbon dioxide transport in this patient, which of the following physiologic processes is taking place? Which of the following pulmonary function test results would most likely be found in this patient? Respiratory (A) Cisplatin (B) Cyclophosphamide (C) Dexamethasone (D) Hydroxychloroquine (E) Rifampin 48. Five days later he develops fever, malaise, a dry cough, and pressure in his chest. He then develops high fever, severe shortness of breath, chest pain, cyanosis, and diaphoresis and is rushed to the emergency department, where work-up reveals hemorrhagic mediastinitis, bloody pleural effusions, and mediastinal widening on x-ray of the chest. A cardioselective b-blocker must be used in cases of asthma to avoid inducing bronchial hyperreactivity. It works by inhibiting the Na+-K+-2Cl- cotransport system of the thick ascending loop of Henle. It is used to increase myocardial contractility in patients with congestive heart failure. Caused by the rupture of a small apical bleb on the surface of the lung, spontaneous pneumothoraces typically present in tall young men. Examination will show decreased breath sounds and hyperresonance on the affected side. X-ray of the chest shows overexpansion of the rib cage and an elevated hemidiaphragm on the affected side. This paradoxical abdominal motion occurs because of the negative intrathoracic pressure that causes the fatigued diaphragm to be pulled into the thorax on the right side. Spontaneous pneumothorax is treated by inserting a chest tube to remove the air from the pleural space. Aortic dissection, not a pneumothorax, would show up on x-ray of the chest as a widened mediastinum. Aortic dissection can occur in trauma, or a dissecting aortic aneurysm can occur in connective tissue diseases such as Marfan disease. The physical findings are not consistent with aortic dissection: first, the chest would not be hyperresonant to percussion and second, the blood pressure would not be equal in both arms. Barrel chests and flattened diaphragms are seen in patients with obstructive lung diseases such as chronic emphysema. Although emphysema is caused by smoking, this patient does not have a long enough smoking history. It is possible that this man could have emphysema due to an a1antitrypsin deficiency, but in that case it would not present this acutely. Consolidation of the right lower lobe on x-ray of the chest usually means pneumonia. Physical exam would show decreased resonance on the affected side and increased fremitus. In tension pneumothorax, a flap-like pleural tear allows air to enter into the pleural cavity, but prevents its exit. It can be caused by penetrating trauma to the chest resulting in increased pleural cavity pressure. Clinical findings include sudden onset of severe dyspnea, tympanitic percussion, and absent breath sounds. There is tracheal deviation and mediastinal structure deviation to the contralateral side. If tension pneumothorax occurs on the left side, there would be compression of venous return to the heart.
If we observe the parts of an animal that a cat eats when it kills a small rodent or bird breast cancer quotes of hope female cialis 10 mg low cost, we see that it does not select exclusively the muscle meat books on women's health issues buy cheap female cialis 20mg on-line. During my biological investigations using animals menstrual flow chart order female cialis 10mg amex, I have had barn rats gnaw their way into the room where the rabbits were kept and kill several animals during a night pregnancy rate buy discount female cialis 20mg on-line. On two different occasions, only the eyes of the rabbits had been eaten, and the blood may have been sucked. It was evident that these rats had a conscious need for special food elements that were provided by these tissues. No phases of the problem of physical degeneration can be as important as knowledge of the forces that are at work and the methods by which they operate. It is clear from the data presented in previous chapters that these forces can become operative with sufficient speed to make a difference in two generations, one succeeding the other. It is also clear from preceding data that these forces originate in the change of the nutrition of the parents. A chemical analysis of the food (Chapter 15), discloses a marked reduction in the intake of some of the vitamins and minerals in individuals who are undergoing a degenerative process. Many investigators have presented important data dealing with the role of vitamin A in prenatal as well as postnatal growth processes. It is known that the eye is one of the early tissues to develop injury from the absence of vitamin A, hence the original name for this vitamin was the xerophthalmic vitamin. The importance of vitamin A to the eye, and the fact that this vitamin is stored in eye tissue have been emphasized by several investigations. Wald (4) in discussing vitamin A in eye tissues states: Extracts of eye tissue (retina, pigment epithelium and choroid) showed the characteristic vitamin A absorption band at 620 mu. The concentration of vitamin A was very constant for different mammals, at about 20 Y per g. This comment is of interest in connection with the observation that I have previously quoted regarding the raid of barn rats on the rabbit cages in the stress of deep winter. While it has been shown that vitamin A is essential for the normal function of eyes, its role in the formation of eye tissues has not been clearly understood. Probably the most sensitive procedure for testing the depletion of vitamin A in domestic animals today is by observing their behavior in semi-darkness. Edward Mellanby (5) has presented important new data dealing with vitamin A deficiency and deafness. He states in an abstract of a paper read before the Biochemical Society, in London in November 1937, the following: In previous publications I have shown that a prominent lesion caused by vitamin A deficiency in young animals, especially when accompanied by a high cereal intake, is degeneration of the central and peripheral nervous systems. In the peripheral system it is the afferent nerves which are principally affected, including the eighth nerve, both cochlear and vestibular divisions. It has now been possible to show that vitamin A deficiency produces in young dogs degenerative changes in the ganglia, nerves and organs of both hearing and balance inside the temporal bone. All degrees of degeneration have been produced, from slight degeneration to complete disappearance of the hearing nerve. The nerves and ganglion cells supplying the organ of Corti are more easily damaged than those of the vestibular division. As might be expected when once the spiral ganglion cells have disappeared, additions of vitamin A to the diet have no effect, and the organ of Corti remains completely denervated. The "inattention" of dogs on these diets which I previously ascribed to cerebral defect is undoubtedly due to deafness. It now remains to determine whether these results may be extended to explain certain forms of deafness in man. The serious effects of deficiency in vitamin A on pregnant rats has been investigated and reported by Mason (6) as follows: Abnormalities are described in the pregnancies of rats maintained on diets deficient in vitamin A in varying degree. Prolongation of the gestation period up to 26 days in severe cases and a long and difficult labour which might last 2 days and often resulted in death of both mother and young were characteristic. Defects due to deficiencies in vitamin A in the diet of dairy animals, (pregnant cows, their offspring and normal calves fed on the milk from those cows) have been reported upon by Meigs and Converse (7) as follows: In 1932 we reported from Beltsville evidence that farm rations frequently fed to calves may be dangerously low in vitamin A, and that milk produced by cows fed hay which has lost its green color may be an unsafe source of vitamin A in the calf ration. This preliminary paper reported results dealing with four cows which had been fed over two years on a good grain mixture and late-cut low-color timothy hay. Of six calves born of these cows, two were dead, one was unable to stand and died shortly after birth, and three were both weak and blind.
It is breast cancer zit cheap female cialis 10 mg without a prescription, of course womens health 50 secret buy generic female cialis 10mg on-line, possible that the father also contributed a poisoned germ cell that constituted a disturbance in the architectural design of the offspring women's health clinic on wright street generic 10 mg female cialis. In this connection breast cancer 1 cm lump order female cialis 20mg without prescription, it is important to have in mind the tragic influence of a program of deliberate starvation of mothers-tobe in order that the bones of the baby may be soft and thus provide an easy birth. Some literature has been published indicating the foods that would be efficient in accomplishing this. She nearly lost her life with the birth of her first baby which was removed by Caesarian operation. Information from many sources may suggest that the expectant mother needs more calcium and more vitamin D. She may go to the pharmacy with a prescription or on her own initiative obtain calcium tablets and socalled vitamin D as a synthetic preparation. We are concerned here with data which will throw light on the comparative value of the treatment the modern mother will thus give herself with that that the primitive mother would provide. Wayne Brehm who is associated with two Columbus, Ohio, hospitals has recently published the results (5) of a study of the effect of the treatment received in 540 obstetrical cases divided into six groups of ninety individuals each, on the basis on which their nutrition was reinforced in order to study the comparative effects of the different treatments. The reinforcement of the diet consisted in Group 1 of taking calcium and synthetic vitamin D as viosterol; Group 2, calcium alone; Group 3, viosterol alone; Group 4, calcium and cod liver oil; Group 5, cod liver oil alone and Group 6, no reinforcement. For those receiving the calcium and viosterol there was extensive calcification in the placentae, marked closure of the fontanelle (the normal opening in the top of the infant skull) and marked calcification in the kidneys. For those receiving calcium alone there was no placental calcification, slight closure of the fontanelle and no calcification of the kidneys. Group 3 receiving viosterol had moderate to marked placental calcification, moderate closure of the fontanelle and no calcification of the kidneys. Those receiving cod liver oil alone had very slight placental calcification, slight fontanelle closure and no calcification in the kidneys. Those receiving no reinforcement had very slight placental calcification, normal fontanelle closures and no calcification of the kidneys. The effect on the mother was a prolonging of labor in Group 1 and at birth the fetal heads were less moulded not being able to adjust their shape to the shape of the birth tube. It is a matter of great importance that the most serious disturbances in reproduction and childbirth are occurring in the most civilized parts of the world. Her data strongly emphasize the necessity that the growing girl shall be allowed to have an active outdoor life not only until the completion of the building of her body at about fourteen years of age, but through the child-bearing period. In practically all countries a restricted sedentary indoor life greatly increases the complications associated with childbirth. She quotes Whitridge Williams to the effect that: "At the onset of pregnancy the (males) are 125 to 100 (females), and he adds that sex is determined in the germ cells, primarily or immediately after their union, and is immutable by the time segmentation of the ovum begins. Vaughan in her reference to the data on the annual report of the chief medical officer, the Minister of Health, states as follows: Our infant mortality returns show that over half the number of infants dying before they are a year old die before they have lived a month (and 6,744 of them before they are twenty-four hours old), strongly suggesting that their vitality was impaired by the process of birth. The figures of those who did not survive one month are 20,060, and of these more than half are males. This destruction of male infants, which goes on day by day and year by year, puts the consequences of the Great War into the shade. Our surplus female population (now reaching over one and a half million in excess of the male) is directly due to it. Civilization does it unaided, for all civilized races as they pass their zenith and are on the downgrade have eventually had to face the same problem, the outnumbering of men by women, and most of them have met it as the East does to-day by female infanticide. We see that difficult childbirth leads to a high maternal mortality, but it is also the cause of a high infant mortality falling most heavily upon the male infants, and it is also responsible for the production of mental defectives in ever-increasing numbers. She shows clearly that the shape of the pelvis is determined by the method of life and the nutrition. In all primitive tribes living an outdoor life childbirth is easy and labor is of short duration. She shows that this is associated with a round pelvis and that the distortion of the pelvis to a flattened or kidney shape, even to a small degree, greatly reduces the capacity and therefore the ease with which the infant head may pass through the birth canal. She has recognized an association between facial and dental arch deformities and deformed pelvis. During my investigations in eastern Australia I was informed that the birth rate among the whites had declined over a large area and to such an extent that many families had no children and many women could produce only one child.
Normal or low Na+ (pseudohyponatremia is artifact menstrual spotting cheap 10 mg female cialis with amex, caused by lipemic serum or hyperglycemia) 5 menstruation question generic 10 mg female cialis with mastercard. Normal or increased serum K+ caused by cellular shifts from acidosis; however women's health big book of abs 4-week exercise plan order female cialis 10 mg without prescription, total body K+ depletion is present from renal losses and is potentially life-threatening menstrual cramps 9 months pregnant 10mg female cialis sale. Dextrose plus insulin is needed to reverse the acidosis from the underlying catabolic process. Too much fluid too quickly or rapid shifts in osmolarity may cause cerebral edema and herniation. Hyperfunction of all the parathyroid glands (hyperplasia)-familial in 20%; a solitary adenoma-typically nonfamilial What are the treatments? Symptoms related to hypocalcemia: tetany, seizures, abdominal pain, numbness of the face or extremities, or carpopedal spasm. Vitamin D2 (ergocalciferol) comes from plant ingestion and is the primary form in food. Hypocalcemia (vitamin D deficiency is the most common etiology in children) with associated symptoms, rickets (see page 137) List 4 metabolic results. Hypocalcemia, hypophosphatemia, high serum alkaline phosphatase (most sensitive indicator of rickets), low 25-hydroxyvitamin D List 7 risk factors fornvitamin D deficiency. Calcitriol (active vitamin D) may be given to treat acute hypocalcemia, but ergocalciferol or cholecalciferol therapy is needed to replenish vitamin D stores. It is an anterior pituitary hormone that causes growth of all tissues, especially bone and cartilage. It promotes mineralization of bones and has a role in carbohydrate and lipid metabolism. Graves disease, autonomous thyroid nodules; subacute thyroiditis, McCune-Albright syndrome, chronic lymphocytic thyroiditis; in infants, neonatal thyrotoxicosis caused by maternal Graves disease What is Graves disease? The most common cause of hyperthyroidism, it is autoimmune hyperthyroidism secondary to diffuse thyroid hyperplasia ("diffuse toxic goiter"). Increased appetite, weight loss, loose frequent stools, heat intolerance, diaphoresis; difficulty sleeping, emotional lability, inattention, hyperactivity, deterioration of school performance, anxiety, weakness and inability to participate in sports, tachycardia, increased systolic blood pressure with wide pulse pressure, tremor, proptosis/exophthalmos, lid lag, pain with eye movement, thyroid gland that is diffusely enlarged, smooth, nontender, and homogeneous with possible bruit, warm, moist, smooth skin, brisk deep tendon reflexes with rapid relaxation phase What is Graves ophthalmopathy? Infection, surgery, trauma, or noncompliance with antithyroid medications What are the therapies for thyroid storm? Congenital hypothyroidism caused by thyroid gland agenesis, dysgenesis, or enzymatic defects Acquired hypothyroidism Which usually occurs after the first year of life, more commonly in adolescent girls Which is more serious & Why? Congenital hypothyroidism, because Thyroid hormone is required for normal brain growth and development during at least the first 2 years of life What may occur if diagnosis is delayed? Disorder may be asymptomatic or mildly symptomatic in early neonatal period, but delay in diagnosis can lead to mental retardation. Frequently, with abnormal newborn screening results; however, some hypothyroid infants will be missed! Slow growth, cold intolerance, decreased energy level, decreased appetite, constipation, irregular menses in adolescent girls, coarse puffy face, flattened nasal bridge, stocky habitus, dull, dry, thin hair, rough, dry, sallow skin, delayed relaxation phase of deep tendon reflexes, school performance isboccasionally impaired. Most commonly, autoimmune destruction secondary to chronic lymphocytic thyroiditis (Hashimoto thyroiditis). Other conditions include surgical or radioactive iodine ablation for the treatment of hyperthyroidism, goitrogens (iodides in cough syrups, seafood and kelp, soy products, cassava, millet, amiodarone, lithium, antithyroid drugs), ectopic thyroid dysgenesis List 4 diagnostic findings. Adrenal insufficiency resulting in decreased cortisol and aldosterone production What is Addison disease? Primary adrenocortical insufficiency because of a destructive autoimmune process List 11 signs and symptoms.