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By: Randolph E. Regal, BS, PharmD
- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
https://pharmacy.umich.edu/people/reregal
Mode of transmission—Direct or indirect contact with skin and scalp lesions of infected people women's health center st luke's buy cheap femara on line, lesions of animals; contaminated fioors womens health group lafayette best 2.5 mg femara, shower stalls breast cancer vaccine 2014 purchase femara 2.5 mg on-line, benches and similar articles women's health issues forum generic femara 2.5 mg fast delivery. Period of communicability—As long as lesions are present and viable fungus persists on contaminated materials. A fungi cidal agent such as cresol should be used to disinfect benches and fioors. Epidemic measures: Educate children and parents about the infection, its mode of spread and the need to maintain good personal hygiene. Period of communicability—As long as lesions are present and viable spores persist on contaminated materials. Educate the public to maintain strict personal hygiene; take special care in drying between to es after bathing; regularly use a dusting powder or cream containing an effective antifungal on the feet and partic ularly between the to es. Epidemic measures: Thoroughly clean and wash fioors of showers and similar sources of infection; disinfect with a fungi cidal agent such as cresol. The nail gradually becomes detached from the nail bed, thickens, and becomes discolored and brittle, an accumulation of soft keratinous material forms beneath the nail or the nail becomes chalky and disintegrates. Diagnosis is made by microscopic examination of potassium hydroxide preparations of the nail and of detritus beneath the nail for hyaline fungal elements. Diarrhea can also occur in association with other infectious diseases such as malaria and measles, as well as chemical agents. Change in the enteric fiora induced by antibiotics may produce acute diarrhea by overgrowth and to xin production by Clostridium dificile. Approximately 70%–80% of the vast number of sporadic diarrheal episodes in people visiting treatment facilities in less industrialized countries could be diagnosed etiologically if the complete battery of newer labora to ry tests were available and utilized. From a practical clinical standpoint, diarrheal illnesses can be divided in to 3 clinical presentations: 1) Acute watery diarrhea (including cholera), lasting several hours or days; the main danger is dehydration; weight loss occurs if feeding is not continued. Direct person- to -person transmission occurs in families, child care centers and cus to dial institutions. Period of communicability—The duration of excretion of the pathogen is typically 1 week or less in adults but 3 weeks in one-third of children. Little is known about differences in susceptibility and immunity, but infections occur in persons of all ages. Reliance on cooking until all pink color is gone is not as reliable as using a meat thermometer. Culture of suspected foods has rarely been productive in sporadic cases except when a specific ground beef item is strongly suspected. Epidemic measures: 1) Report at once to the local health authority any group of acute bloody diarrhea cases or cases of hemolytic uraemic syndrome or thrombotic thrombocy to penic purpura, even in the absence of specific identification of the causal agent. Identification—A major cause of travellers’ diarrhea in people from industrialized countries who visit developing countries, this disease is also an important cause of dehydrating diarrhea in infants and children in the latter countries. Transmission via contaminated weaning foods may be particularly important in infection of infants. Direct contact transmission through fecally contaminated hands is believed to be rare. The organisms possess the same plasmid-dependent ability to invade and multiply within epithelial cells. For the rare cases of severe diarrhea with enteroinvasive strains, as for shigellosis, treat using antimi crobials effective against local Shigella isolates. Diarrheal disease in this category is virtually confined to children under 1 in whom it causes watery diarrhea with mucus, fever and dehydration. However, it remains a major agent of infant diarrhea in many developing areas, including South America, southern Africa and Asia. It is not known whether the same incubation applies to infants who acquire infection through natural transmission. Since diarrhea can be induced experimentally in some adult volunteers, specific immunity may be important in determining suscepti bility. Preventive measures: 1) Encourage mothers to practise exclusive breastfeeding from birth to 4–6 months. Where available, and only if a mother’s breastmilk is unavailable or insuficient, give newborns pasteurized donor breastmilk until they go home. In special care facilities, separate infected infants from those who are premature or ill in other ways. No common bathing or dressing tables should be used, and no bassinet stands should be used for holding or transporting more than one infant at a time. In communities with adequate sewage disposal system, feces can be discharged directly in to sewers without preliminary disinfection. For severe enteropatho genic infant diarrhea, oral trimethoprim-sufamethoxazole (10–50 mg/kg/day) has been shown to ameliorate the sever ity and duration of diarrheal illness; it should be administered in 3–4 divided doses for 5 days. Epidemic measures: For nursery epidemics (see section 9B1) the following: 1) All babies with diarrhea should be placed in one nursery under enteric precautions. For babies exposed in the contaminated nursery, provide separate medical and nursing personnel skilled in the care of infants with communicable diseases. Observe con tacts for at least 2 weeks after the last case leaves the nursery; promptly remove each new infected case to the single nursery ward used for these infants. Maternity service may be resumed after discharge of all contact babies and mothers, and thorough cleaning and terminal disinfection. It was subsequently recognized in India as being associated with persistent diarrhea (continuing unabated for at least 14 days), an observation that has since been confirmed by reports from Bangladesh, Brazil and Mexico. The characteristic lesion, caused by liberation of a specific cy to to xin, is an asymmetrical adherent greyish white membrane with surrounding infiammation. The throat is moderately to severely sore in faucial or pharyngo to nsillar diphtheria, with cervical lymph nodes somewhat enlarged and tender; in moderate to severe cases, there is marked swelling and oedema of the neck with extensive tracheal membranes that progress to airway obstruction. Nasal diphtheria can be mild and chronic with one-sided nasal discharge and excoriations. The to xin can cause myocarditis, with heart block and progressive congestive failure beginning about 1 week after onset. Case-fatality rates of 5%–10% for noncutaneous diphtheria have changed little in 50 years. If diphtheria is strongly suspected, specific treatment with antibiotics and anti to xin should be initiated while studies are pending and continued even in the face of a negative labora to ry report. Infectious agent—Corynebacterium diphtheriae of gravis, mitis or intermedius biotype. Non to xigenic strains rarely produce local lesions; however, they have been increasingly associated with infective endocarditis. Occurrence—A disease of colder months in temperate zones, primarily involving nonimmunized children under 15; often found among adults in population groups whose immunization was neglected. In the tropics, seasonal trends are less distinct; inapparent, cutaneous and wound diphtheria cases are much more common. A massive outbreak of diphtheria began in the Russian Federation in 1990 and spread to all countries of the former Soviet Union and Mongolia. This epidemic declined after reaching a peak in 1995; it was responsible for more than 150 000 reported cases and 5000 deaths (1990–1997). In Ecuador, an outbreak of about 200 cases, half of whom were 15 or older, occurred in 1993–94. Disease or inapparent infection usually, but not always, induces lifelong immunity. Many of these older adults may have immunological memory and would be protected against disease after exposure. Anti to xic immunity protects against systemic disease but not against colonization in the nasopharynx. The first 3 doses are given at 4 to 8-week intervals beginning when the infant is 6 8 weeks; a fourth dose 6–12 months after the third dose. A fifth dose is given at 4–6 years prior to school entry; this dose is not necessary if the fourth dose was given after the fourth birthday. Limited data from Sweden sug gest that this regimen may not induce protective anti body levels in most adults, and additional doses may be needed. Where culture is impractical, isolation may end after 14 days of appropriate antibiotherapy (see 9B7). Those who handle food or work with school children should be excluded from work or school until proven not to be carriers.
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Pharmacists should refer to breast cancer marathon proven 2.5 mg femara their professional association and/or their employers for guidance in this area women's health redding ca femara 2.5mg visa. It is the responsibility of the individual pharmacist to the women's health big book of exercises pdf download cheap femara 2.5mg amex ensure that they are prescribing within their own area of competency (see Regulation 21 menstruation on depo provera order femara 2.5 mg free shipping. There will be subsets of the population, such as pediatric, immunocompromised, pregnant and lactating, and geriatric patients, which require a more specialized knowledge base. While there are no restrictions for prescribing within these patient groups, the pharmacist must be confident that he/she has the knowledge and competency to do so. While neither Herpes Zoster, malaria prophylaxis or treatment for traveler’s diarrhea are considered minor ailments, they are considered preventable diseases for which the pharmacist can advise and treat when appropriate, and when the pharmacist has the necessary knowledge base and competency to prescribe. Will there be communication and education to the public to help them understand the new role of pharmacists with regard to prescribing for Minor Ailmentsfi We will be developing a communication plan to educate the public on these new roles and what they can expect from their pharmacist as well as what their responsibility is in looking after their own health. Depending on the clinical situation, you may decide, or the client may request you, to communicate with more than one physician, or other health care providers. Will malpractice liability insurance requirements change now that pharmacists are accountable for the decisions made when prescribing for minor ailmentsfi Prescribing by pharmacists reflects many roles that pharmacists already performed prior to the enabling legislation. Having said that, you must recognize that becoming formally involved in prescribing means you will inherit an increased proportion of risk and liability. Knowledge, competency and quality information are important to making informed decisions. Each pharmacist will develop their own routines and methods for performing this activity as they gain experience in adopting this “new” role. Some interesting suggestions, from Paul Bazin, a pharmacist in Saskatchewan, are included here: “Time management is important. With experience, he finds it only takes about 10-15 minutes to take a full patient his to ry and prescribe the appropriate medication. It helps to be familiar with forms and guidelines, and to know what you want to say when you sit down with the patient. To speed the process, Bazin keeps printed forms and guidelines readily available in a binder. He separates the seven minor ailments by indexed tabs, so he can quickly look up the differential diagnoses, prescriptions, and requirements for physician referrals. After a consult, he transfers forms to a separate section, to meet follow-up requirements for each condition. This structured guide increases a pharmacist’s confidence in the programs, especially at first, he explains. During busy times of the day, a pharmacy technician will triage patients while he is counselling. However, many patients with minor ailments will come in for help in the evening, when he is alone on a shift. At those times he will extend waiting periods, or put out a sign informing patients that he is counselling someone. He finds cus to mers have few issues with waiting, because they know they can expect the same quality service from him when it’s their turn. To help educate the public, Bazin makes pamphlets readily accessible on the desk and displays, and give them take-aways along with related prescriptions. He has educated pharmacy technicians and clerks on what to tell people if they ask about the service. Answer 1: the act of prescribing and dispensing drugs by pharmacists is similar to other practitioners who prescribe services, then provide them. Examples include physicians, dentists, veterinarians, chiroprac to rs, physical therapists, all of whom assess the patient and recommend the services needed, then, if the patient agrees, provide the services. Just like other health professionals, pharmacists must practice according to a strict code of ethics. In addition, stringent standards of practice define the expectation that pharmacists will separate the prescribing and dispensing functions whenever possible. If concerns about a perceived role conflict arise, the College will adjudicate them against the Standards of Practice and the Code of Ethics to determine whether the conduct was in the best interest of the patient. Answer 2: Pharmacists are taught to make the best recommendation for that patient, not to sell products. Hugs and kisses would do just as well as cough syrup (cough syrup might not be effective in children, and can often result in harm due to accidental overdose). Pharmacists are taught to make the best recommendation for that patient, not to sell products. If there is a beneficial product that your 27 | P h a r m a c y A c t 2 0 1 4 M i n o r A i l m e n t s | M a n d a t o r y o r i e n t a t i o n pharmacist can recommend, great; if the pharmacist can manage your ailment without drugs, even better (no drugs, no side effects, no problems) 24. As part of the communications plan being prepared by the College, we will look at preparing templates for leaflets and posters which pharmacies can make available to the public. We will work with the New Brunswick Pharmacists Association to develop suitable materials. If you have questions after reading, you should seek legal advice on what you can, and cannot, advertise. One way to explain this to the patient is to say that depending on the ailment, you may have more treatment options available to draw from while treating the ailment than you did in the past. For example, in treating acne, a prescription product may be a better choice than one available over-the-counter, but in the past, that option was not possible. Because of the wider choice of treatments, a more detailed assessment may be required in order to treat most appropriately. Once the new Act and Regulations have been proclaimed (declared in to law) in the Legislative Assembly, then all members may practice, based on their knowledge base and skill level, within the legislation, once they have declared they have met the criteria established by the College. What do I do if the patient’s physician disagrees with my diagnosis or treatment when notifiedfi If you have assessed, prescribed and documented appropriately, and have chosen a recognized treatment, then discussing your decision with the physician is the best course to take. This is not unlike in the past, when you as a pharmacist had concerns about a prescription a physician may have written, and called to discuss those concerns on behalf of the patient. Should I charge for that follow-up or is it included in the initial assessment feefi Follow-up can be arranged with the patient, and can be done by phone or in person, whichever seems most appropriate and convenient. While the College cannot speak for third party payers and assigning fees, most follow-up would be included as part of the original assessment. Occasionally, a more complicated situation may warrant a second visit and/or assessment. While following up may be as simple as asking the client to call you, or return to the pharmacy, in a certain number of days if they are not better, taking the initiative yourself is a better practice. I am comfortable assessing and prescribing for minor ailments but other pharmacists at this location are not. Do you have suggestions on how we can deal with this so the patients don’t get confused with what to expectfi Acting as a positive role model and men to r during the startup phase will go a long way to bring your fellow pharmacists along with you. Point out that each pharmacist can start with just a few minor ailments, and add more as they become more comfortable with the learning curve. Brains to rm as a team how to work to gether to create efficiencies within the pharmacy workflow. For what time period must the assessment and prescribing documentation records be keptfi As these records are patient specific and record clinical information and decisions, they fall under the same retention requirements as prescriptions, that is, for fifteen years. If documents are scanned electronically, the paper copies need to be retained for two years, and the electronic files, for fifteen years. Consent cannot exist if the client is not informed of potential risks or side effects to standard treatments, invasive procedures or alternative treatments. If "informed consent" becomes an issue (malpractice suit, allegation of an assault, you "ruined my vacation", etc. For that reason, written and signed consent is always best, otherwise it becomes the word of the professional against the client.
Tere were no diferences in the burden of data; the limitations of these data are described in Ontario breast cancer 8mm order femara mastercard, we calculated disease burden using an rubella between males and females breast cancer 82 years old buy discount femara 2.5mg online, and most of greater detail in Chapter 5 menstrual android buy 2.5mg femara overnight delivery. It can lead Health State Percentage of Duration Severity Weight Number of Cases to womens health 4 week diet purchase femara 2.5mg visa orchitis (infammation of the testicle) in post Reported Mumps Expected to pubertal men. We used epidemiologic no diferences in disease burden between males and data; the limitations of these data are described studies to determine the percentage of reported females, and the vast majority of disease burden in greater detail in Chapter 5. Tere is a high mumps cases that progressed to orchitis, deafness, afected those aged 15–44. Tetanus can Health State Percentage of Duration Severity Weight Number of Cases occur afer bacterial spores enter the body through Reported Tetanus Expected to wounds caused by contaminated objects. They release Cases per Year that Develop Health Progress to Each State a to xin in the body that causes muscles to contract Health State in involuntary and prolonged spasms. A vaccine series is ofered during childhood, and booster vaccines are provided during adulthood Estimated burden Limitations or given along with tetanus immunoglobulin afer a We estimated annual averages of 0 deaths and one Tese estimates for the burden of tetanus are high-risk exposure. We used epidemiologic studies to determine the duration of illness for an acute episode of tetanus. It is one of Reported Measles Expected to the most infectious of all known pathogens. Complications of the infection include episode of measles diarrhea, pneumonia and early or delayed encephalitis Otitis media 6. Tere is the possibility measles from Ontario’s reportable disease database afected children aged 0–4 years. It should be noted that the most recent measles outbreak in 2008 occurred afer our study period. It has Reported Diphtheria Expected to a human reservoir and is spread by physical contact Cases per Year that Develop Health Progress to Each State or inhaling contaminated droplets. Anti to xins are available and a vaccine series to prevent infection is ofered in childhood with Estimated burden can also cause milder infections which present as boosters in adolescence and adulthood. The importance of continued vigilance any epidemiologic studies with empirical data. The most in to three states (pulmonary, extra-pulmonary-non common manifestation is pulmonary (lung) lymph node, and extra-pulmonary-lymph node). Most infections are Health State Duration Severity Weight Episode Length Number of Cases endogenous (from the patient’s own fora) with risk Expected to Develop fac to rs including antibiotic use, hospitalization, Health State gastrointestinal surgery, indwelling catheters, Candidiasis – 2. It should be noted that therefore, not being captured in the health utilization determine the number of deaths due to non-invasive there were nearly twice as many incident cases of non data, as well as the data quality issues associated with candidiasis, semi-invasive candidiasis and invasive invasive candidiasis in females. We estimated annual averages of four deaths and Tese estimates for the burden of Pneumocystis are Trimethoprim-sulfamethoxazole is the treatment 177 health care utilization episodes attributable to limited by the sources of uncertainty arising from of choice, and is also used as prevention in high risk Pneumocystis. The vast majority of disease burden symp to matic cases not seeking medical attention and, patient populations. We used epidemiologic very little to the overall disease burden, it is unlikely studies to determine the duration of illness for that adjustment would have signifcantly changed the pneumocys to sis. Disease burden due to Aspergillus is symp to matic cases not seeking medical attention determine the number of deaths due to non-invasive higher in males, which can be attributed to more and, therefore, not being captured in the health aspergillosis, pulmonary invasive aspergillosis, and recorded Aspergillus deaths among males; however, utilization data, as well as the data quality issues non-pulmonary invasive aspergillosis. However, due to the severity and duration of the determine the number of episodes of non-invasive Most of the disease burden was among individuals symp to ms due to aspergillosis, most infected aspergillosis, pulmonary invasive aspergillosis and over the age of 45. We used Fatalities due to Aspergillus will be underestimated epidemiologic studies to determine the duration of because our source of mortality data only listed illness for each health state. Most cases of Aspergillosis occur in patients with severe underlying lung disease or immunodefciency, and deaths hastened by Aspergillus may have been coded according to the underlying disease which predisposed to Aspergillus infection. The infection is usually disseminated acquired by inhalation, and the most common manifestation of blas to mycosis is chronic pulmonary (lung) infection. Treatment requires 55 health care utilization episodes attributable to limited by the sources of uncertainty arising from prolonged antifungal therapy. Almost the entire disease burden of data, as well as the data quality issues associated determine the number of deaths due to pulmonary Blas to myces was among males as all six observed with the health care utilization data. Moreover, our data are similar to the results of a previous labora to ry based surveillance study in Ontario which identifed 309 cases over a 10-year period from 1994–2003. Our study methodology has not included an attempt to defne the intra-provincial distribution of this disease burden. Ontario Burden of Infectious Disease Study Chapter 4 / Methods and Results by Infectious Agent Institute for Clinical Evaluative Sciences Ontario Agency for Health Protection and Promotion 116 4. Since there were no recorded his to plasma from symp to matic cases seeking medical attention (lung) infection. Afer a few summers with many symp to matic cases not seeking medical attention Ontario cases, we have seen far lower disease activity. More years of study would need to be of dengue fever are quite severe, and it was expected disease burden where all episodes/deaths of a added in order to establish age and sex trends of the the majority of individuals infected would seek syndrome were attributed to only dengue and no disease burden of dengue. Dengue health care utilization data to determine the number also exemplifes the difculty in precisely estimating of episodes of dengue fever (classical dengue) or disease burden for infections with low case fatality dengue haemorrhagic fever. The disease is typically Reported Malaria Cases per Year that characterized by cyclical fever, pain, and anemia. Progress to Health Cases caused by Plasmodium falciparum (one State of fve malarial species), can produce a range of Plasmodium falciparum – 59 1 week 0. Tere are also data quality issues Public Health Labora to ry of Ontario (where 75% of of disease burden attributed to malaria was a result associated with the reportable disease and labora to ry reported malaria cases in Ontario are confrmed) of premature mortality. Expert the overall disease burden, it is unlikely that adjustment opinion was used to determine the duration of each for underreporting would have signifcantly changed type of malaria. Almost all infections are State acquired during travel to developing countries, Acute infectious episode of 100 4 weeks175 0. We used epidemiologic studies to determine the duration of typhoid/paratyphoid fever. Although the use of health care utilization data to Static nature of burden supplement reportable disease data in burden of Use of the pathogen-based approach of disease methodology disease studies is not novel, we are not aware of any One advance from previous burden of disease One important assumption common across all previous studies that were able to link individuals studies is that we used the pathogen-based approach studies based on the Global Burden of Disease across datasets. In comparison, a pilot study estimating the to a static assessment of the burden of infectious burden of infectious diseases in Europe included only investigative team brought tremendous clinical and diseases by: using the available Ontario data and seven infectious agents. The limitations of this study are We included a greater range of health states mortality, and the full impact of real and potential presented in three sections: those that afected the representing longer-term sequelae of infectious outbreaks. Ontario Burden of Infectious Disease Study Chapter 5 / Strengths and Limitations Institute for Clinical Evaluative Sciences Ontario Agency for Health Protection and Promotion a burden of disease study. Not accounting for other comorbidities state distribution and duration, severity weights, burdens. For example, there are tremendous may have led to overestimating the disease burden and mortality; all disaggregated by age and sex). Other also did not directly assess the proportion of burden the distributions obtained from prior epidemiologic burden of disease studies have raised the concern of related to antibiotic resistance and health care studies may not be representative of the distribution “junk codes” that represent ill-defned conditions acquired infections, both of which are important in Ontario at the present time, especially if a. We were through our syndrome-based approach to estimate Use of different time frames for also ofen unable to distinguish between infectious disease burdens of various infectious agents. This was necessary because the acquired in these settings, and the interventions morbidity and mortality for certain non-traditional availability of the data varied by source. Teir burden purposes of billing the Ontario Health Insurance using health administrative data), as well as the would have been signifcantly higher had another Plan (for ofce visits), but their accuracy for timescale of the project, we did not include certain time frame been used. However, our methodology provides a The results here may be limited in the future for procedures) matched in 94%. Most responsible useful framework for the addition of these pathogens, interpretation of disease burden. Some infectious agents could be the mortality data were compiled, the most recently cases is acceptable because they do not contribute considered under more than one disease grouping available data were from 2005. Unfortunately, we were able to adjust for Bacterial Infections group and hepatitis B was is anticipated in the near future. Most infectious diseases so could have reasonably been included under the comparisons, it was a deliberate decision by the are of short duration, so most instances of reportable Common Bacterial Infections group. Consequently, many deaths are attributed to non-infectious causes even if some of cases of blood-borne viruses underestimates the Burden of undiagnosed/ those deaths may have been precipitated or hastened underreported cases impact of prevalent cases diferentially in some by an infectious agent. Our estimates generally do not include cases that to consider an infectious etiology, incomplete had symp to ms but did not seek medical attention Health care utilization data quality investigation for diagnosing infectious diseases or and/or were not diagnosed and reported, although Health care utilization data in Ontario are collected misattribution of the cause of death. While this limitation health care system, and are used secondarily for underlying illness. For example, For the physician claims data, only a single diagnostic severe infections. Additionally, the codes are not data from Ontario’s public health labora to ry Reportable disease data quality comprehensive, with some diseases lacking codes.
Finally menopause that 70s show discount femara 2.5mg on-line, if disease is extending performed where the peri to breast cancer 5k in washington dc purchase femara uk neum of the pelvic sidewall is to pregnancy 6 weeks cramping discount femara 2.5 mg visa the obtura to birth control for women's health generic femara 2.5mg line rs and to the hypogastric refection, level excised to the extent of involvement with endometriosis. Another alternative is to implement hydrodistention underneath the peri to neal layer may assist the suture ligation using the anterior approach from the prevesical surgeon in recognizing deeper implants. After the identifcation of the When the ovarian vessels are ligated bilaterally and there uterine artery, the diseased peri to neum is excised all the way are well-placed sutures on the uterine arteries, the uterus to the uterine artery tunnel. Suture ligation is always preferred over energy-based modalities, like the At this juncture, the uterosacral ligament and its presacral harmonic scapel and bipolar electrocautery. The procedure attachments, which is the refection of the inferior hypogastric will then proceed by dissecting the posterior cul-de-sac. At the endometriotic implants and their adjacent peri to neum can be same time, the uterus is anteverted with its manipula to r. An elliptical incision is made around the lesion, its from its posterior uterine and posterior cervical and vaginal edge lifted upward, and the lesion is undermined using the involvement. Following excision with scissors, Tuttlingen, Germany) is used to lift up the ovaries if they the ureter, the anterior rectal wall, and the upper posterior are attached by adhesions to their respective utero-sacral vagina are checked and superfcial endometriosis in these ligament and/or pelvic sidewall. A blue dye contrast may aid the surgeon in drainage of an endometrioma from the undersurface of the to detect occult and atypical peri to neal lesions (Aqua Blue ovary. If no endometrioma is readily identifed, and the patient Contact Technique) (Figs. The base of the lesion must either of these two methods, the cyst cavity is rinsed with also be excised until normal tissue is seen. Cold scissors with Ringer’s lactate solution and then excised using 3-mm and microbipolar back-up may result in better outcome due to their 5-mm biopsy forceps, grasping forceps, and/or scissors. This step is particularly the dissection is performed until the loose areolar tissue of useful near the utero-ovarian ligament as rough avulsion can the rec to -vaginal space is reached. Grasping forceps are then used extends 3–4 centimeters below the posterior fornix. Another to stabilize ovarian cortex while the endometrioma cyst wall technique in reaching the rec to vaginal disease is performed by is avulsed. Excision can be performed with minimal bleeding exploring the pararectal space bilaterally. Only after the rectum from the cyst wall bed and the ovarian wall edges usually re is mobilized should excision of the fbrotic endometriosis be approximate quite well, though occasionally extracorporeal attempted from the rectum, posterior vagina, and utero-sacral suturing is required. When a ureter is close to the lesion, its course in the deep pelvis is traced by opening its overlying peri to neum with scissors. Microbipolar forceps are used to control arterial Cul-de-Sac Excision and venous bleeding. The rectum, with or without a fbrotic lesion must be separated from the posterior uterus and upper vagina, especially when Partial cul-de-sac obliteration means that deep fbrotic operating close to the uterine vessels, as entry in to these endometriosis, i. The deep fbrotic endometriosis is usually located on the rectum, in the rec to vaginal space, on the upper vagina, in the Following separation of the rectum from the back of uterus and space between the upper vagina and the cervix (cervicovaginal the upper posterior vagina, the dissection continues on to p of angle), or in one or both utero-sacral ligaments. With deep cul the posterior vagina, the position of which is confrmed by the de-sac obliteration, fbrotic endometriosis and/or adhesions sponge in the posterior fornix. This dissection on the outside involve the entire area between the cervico-vaginal junction of the vaginal wall uses laser, aquadissection, electrosurgery (and sometimes above) and the rec to -vaginal septum. Dissection should be performed accordingly with removal of all visible fbrotic Careful inspection of the cul-de-sac is necessary to evaluate endometriosis. Lesions extending to tally through the vagina the extent of upward tenting of the rectum. To determine if cul demand an en bloc resection from cul-de-sac to posterior de-sac obliteration is partial or complete, a sponge on a ring vaginal wall as part of the extended hysterec to my. Complete stage, the surgical team may also perform a low anterior rectal cul-de-sac obliteration implies that the outline of the posterior resection if rectal stricture is present, or the anterior surface of fornix cannot be visualized initially through the laparoscope, the rectum is compromised due to wide excision. Partial cul Our recommendation is to defer the low anterior segmental de-sac obliteration occurs where rectal tenting is visible but resection until after the hysterec to my is completed. The reason a protrusion from the sponge in the posterior vaginal fornix is for this is that the natural orifce of the vagina could be used noted between the rectum and the inverted ‘U’ of the utero as an access route for the resected bowel to be removed. At this step the ureter is completely exposed rectum can be excised laparoscopically without entering bilaterally. Then, following the placement of rectal, occur during hysterec to my surgery, especially when excising vaginal, and uterine probes, the rectal serosa is opened at its rectal endometriosis nodules. These defects concentrating on the excision of the nodular mass, attention are detected by flling the rectum and rec to sigmoid with a is frst directed to the complete dissection of the anterior blue dye solution. Full thickness rectal lesion excisions can rectum throughout its area of involvement. If bowel resection is deemed necessary, it will be forceps coagulate the uterosacral ligaments. In order to prevent entered posteriorly over the uterovaginal manipula to r below complications, surgeons are cautioned against the use of the cervicovaginal junction. A 4-cm-diameter reusable vaginal active suction drains or mechanical suction drain pumps. In addition, scalpel, or electrosurgery to complete the circumferential juxtapositional alignment of suture repair lines must be culdo to my with the delinea to r as a backs to p. The specimen avoided when full thickness organs, such as the ureter, bowel, of the uterus with its contiguous tissues (posterior vagina bladder and vagina, are simultaneously repaired. Mobilizing an and parametrium, along with tubes and ovaries attached) is omental pedicle pad in between the repaired organs may also removed from the vagina. The uterus is morcellated vaginally, be considered in order to prevent rec to vaginal, uretrovaginal, if necessary, and pulled out of the vagina. Extrafascial culdo to my with removal of the entire uterus is When very low anterior bowel reanas to mosis is performed or followed with anchoring of the vaginal cuff to the uterosacral a compromised bowel wall tissue is suspected, a prophylactic ligaments. Culdo to my proximal to the When endometriosis involves the parametrium, the uterine uterosacral ligament insertion site preserving Level 1 support and bowel may also be involved. In this surgically challenging situation, the uterine important, the uterosacral insertions are the most common arteries are ligated proximally at the hypogastric level or the site of deep endometriosis, and, if left behind, may contribute internal iliac artery level. The detachment of deep fbrotic tissue from parametrial extension in frozen pelvis is the most challenging Laparoscopic Vaginal Vault Closure and Suspension with McCall aspect of a modifed radical hysterec to my. These lesions may Culdoplasty extend to the level of the obtura to r vessels and deep in to the vaginal delinea to r tube is placed back in to the vagina ischial spine. The ureteral stents since the ureters are almost always encased uterosacral ligaments are identifed by bipolar desiccation within this fbrotic process. The frst suture is ureter during this excision should be immediately repaired complicated as it brings the uterosacral and cardinal ligaments, with 4. This single suture whereas primary lesions on the rectum are closed with is tied extracorporeally, bringing the uterosacral ligaments, interrupted silk in a single layer. After the disease-free tissues cardinal ligaments, and posterior vaginal fascia to gether are reached, both anteriorly and posteriorly, the cardinal across the midline. It provides excellent support to the vaginal ligaments are taken down either with a harmonic scalpel or cuff apex, elevating it and its endopelvic fascia superiorly and pure cut electrical current. The rest of the vagina and overlying pubocervicovesicular fascia are closed vertically with one or two 0-Vicryl interrupted sutures. They Removal of uterosacral ligaments with its presacral attachment are used for support, not hemostasis. Strangulating sutures and deep hypogastric extensions is again performed since that inhibit tissue circulation are avoided. A drain is never the disease usually affects the proximal part of the uterosacral used. However, deep nodules and cystic lesions may and poor drainage and are never used. Extreme caution must be practiced as well as avoidance of bilateral deep excisions in order to prevent the potential for serious bladder dysfunction secondary to injury of the deep hypogastric nerve. The vertical intra-umbilical incision is closed with a single 4-0 the modifed McCall culdoplasty procedure is performed Vicryl suture opposing deep fascia and skin dermis, with the when the cuff is closed vertically in two layers (Figs. This will prevent the suture When the cuff is closed horizontally, modifed Richardson from acting like a wick transmitting bacteria in to the soft tissue angle sutures are applied (Fig. Cys to scopy is done after vaginal closure to check for ureteral patency in most cases, after intravenous administration of indigo carmine dye.
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