- Congenital diaphragmatic hernia (CDH) and diaphragmatic eventration (DE) are congenital diaphragmatic malformations that result from abnormal development of the diaphragm. DE involves an abnormally thin diaphragm while CDH is a defect or abnormal attachment.
- For newborns with CDH, the current standard of care is delayed surgical repair after stabilization along with therapies like nitric oxide and ECMO. Surgery is rarely needed for asymptomatic DE in children.
- In adults, an elevated diaphragm is attributed to a congenital cause only after ruling out other etiologies, and surgery may be indicated for symptomatic DE or when it
CONGENITAL DIAPHRAGMATIC HERNIA- PEDIATRIC SURGERY
#surgicaleducator #congenitaldiaphragmatichernia #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Congenital Diaphragmatic Hernia
• I have discussed definition, pathology, antenatal diagnosis, postnatal diagnosis, pre-op stabilization, prognostic factors, treatment and long-term followup of CDH.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
CONGENITAL DIAPHRAGMATIC HERNIA- PEDIATRIC SURGERY
#surgicaleducator #congenitaldiaphragmatichernia #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Congenital Diaphragmatic Hernia
• I have discussed definition, pathology, antenatal diagnosis, postnatal diagnosis, pre-op stabilization, prognostic factors, treatment and long-term followup of CDH.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
About traumatic diaphragmatic hernias
Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes
Every blunting of CP Angle in trauma pts must raise the possibility
Varied clinical spectrum.
Can be repaired by general surgeons themselves with good results
Associated injuries often influence the eventual outcome
About traumatic diaphragmatic hernias
Incidence in the foothills of the Himalayas may be higher than the plains- relation to climbing trees for animal fodder or falls from roads in hills onto trees or slopes
Every blunting of CP Angle in trauma pts must raise the possibility
Varied clinical spectrum.
Can be repaired by general surgeons themselves with good results
Associated injuries often influence the eventual outcome
ANESTHETIC MANAGEMENT OF TRACHEOESOPHAGEAL FISTULA by Dr.Sravani VishnubhatlaDrSravaniVishnubhatl
Learning Objectives:
Review the clinical presentation of a patient with tracheoesophageal fistula (TEF)
Understand the prevalence of TEF, types, and associated syndrome
Discuss the diagnosis of TEF
Describe the medical and surgical management of TEF
Understand the anesthetic-related implications and develop an anesthetic plan
The neonatal bowel obstruction is suspected based on polyhydramnios in utero, bilious vomiting, failure to pass meconium in the first day of life, and abdominal distension.The presentations of NBO may vary. It may be subtle and easily overlooked on physical examination or can involve massive abdominal distension, respiratory distress and cardiovascular collapse.Unlike older children, neonates with unrecognized intestinal obstruction deteriorate rapidly.
Neonatal bowel obstruction is grouped into two general categories: high, or proximal, obstruction and low, or distal obstruction, both of which are suspected by failure to pass meconium at birth. High obstruction can be suspected based on the double bubble sign. Cases without distal gas are usually related to duodenal atresia, while high obstruction with distal gas need an upper gastrointestinal series because of the need to distinguish duodenal web, duodenal stenosis and annular pancreas from midgut volvulus, the latter being a surgical emergency. Confirmation is ultimately by surgical intervention.
Jejunal and ileal atresia are caused by in utero vascular insults, leading to poor recanalization of distal small bowel segments, a condition in which surgical resection and reanastamosis are mandatory. Hirschsprung disease is due to an arrest in neural cell ganglia, leading to absent innervation of a segment distal bowel, and appears as a massively dilated segment of distal bowel on contrast enema. Surgical resection is necessary for this condition as well. Imperforate anus also requires surgical management, with the diagnosis made by inability to pass the rectal tube through the anal sphincter.[6] Supportive intravenous hydration, gastric decompression, and ventilatory support may be needed due to poor neonatal nutrition resulting from dysfunctional bowel absorption.
A low obstruction is suspected on plain film, but needs follow up with a gastrografin enema, which itself can be therapeutic. The differential for low obstruction is ileal atresia, meconium ileus, meconium plug syndrome and Hirschsprung disease. In cases of meconium ileus or ileal atresia, the colon distal to the obstruction is hypoplastic, usually less than 1 cm in caliber, as development of normal colonic caliber in utero is due to the passage of meconium, which does not occur in either of these conditions. When diffusely small caliber is seen, it is referred to as microcolon. Radiographs in meconium ileus classically demonstrate a bubbly appearance in the right lower quadrant due to a combination of ingested air and meconium. If, on contrast enema, reflux into the dilated distal small bowel loops can be achieved, the study is both diagnostic and therapeutic, as the ionic contrast medium can dissolve the meconium to allow passage of enteric content into the unused colon.
If contrast cannot be refluxed into the distal small bowel, ileal atresia remains a diagnostic possibility.
With early intervention, morbidity and mortality.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
1. A R D I A N S Y A H
Cardiothoracic and Vascular Surgery Trainee
University of Indonesia
2.
3. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
4. Congenital diaphragmatic
hernia (CDH)
Lost of continuity or
sometimes its normal
attachment to the costal
margin
Diaphragmatic
eventration (DE)
An abnormally thin and fibrous
diaphragm secondary to incomplete
development of a part or the totality of
muscular components (complete and
unbroken)
Kotecha S, Barbato A, Bush A, et al. Congenital Diaphragmatic Hernia. European Respiratory Journal.
2012;39(4):820-829. DOI: 10.1183/09031936.00066511
5.
6. Incidence: 1 in 3000 to 5000 live births (live births vs. stillbirths)
40% of cases with associated anomalies
The presence of such associated anomalies worsens the prognosis very significantly,
with a mortality rate of almost 80%
Majority: isolated CDH with pulmonary hypoplasia and PPHN
• May not be secondary to a defect of muscularization but rather to a malformation of
the a-muscular mesenchymal components
• May have developed from a small congenital defect enlarging over time secondarily
to an increase in intra-abdominal pressure caused by physical exertion, childbirth,
obesity, and so on
• A traumatic cause is difficult to rule out
Different in pediatric and adult (more commonly on right side)
7. Chandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. Congenital Diaphragmatic hernia - a review. Matern Health Neonatol Perinatol. 2017;3:6.
doi:10.1186/s40748-017-0045-1
Bochdalek
Failure development or fusion of
pleuroperitoneal membrane (occurs around
8th week of gestation)
Posterolateral portion
Left-sided in 90%
Contents of hernia:
• Left: stomach, spleen, colon
• Right: liver, kidney, omentum
Mostly do not have true hernia sac
Morgagni
Herniation occurs in sternocostal hiatus,
through which the superior epigastric vessels
pass from the abdomen to the retrosternal
area
Less common
More common on right side
Contain: mostly omentum; colon, small
bowel, stomach
All have sac
8. Chandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. Congenital Diaphragmatic hernia - a review. Matern Health Neonatol Perinatol. 2017;3:6.
doi:10.1186/s40748-017-0045-1
Recent hypothesis:
• The initial insult occurs during the stages of
organogenesis resulting in bilateral hypoplasia,
followed by compression of the ipsilateral lung
secondary to the herniation of the abdominal
viscera at later stages
• Explains the variability of lung hypoplasia on the
contralateral side, decreased branching of the
bronchioles and pulmonary vessels leading to
acinar hypoplasia, decreased terminal
bronchioles with thickening of alveolar septa
• The lung is relatively immature, hypoplasia of
pulmonary vasculature leads to PPHN
Defective
diaphragmatic
muscle
Intra-abdominal
content thoracic
cavity
Secondary
associated lung
hypoplasia
9. Reduced total
pulmonary
vascular bed,
decreased
number of
vessels per unit
of lung
• Altered
vasoreactivity,
impaired
endothelium-
dependent
relaxation of
PA, imbalance
between
vasoconstrictor
and vasodilator
mediators
• PAH, RVH/RVF,
left ventricular
hypoplasia with
PVH
PPHN:
10. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
Prenatal diagnosis using ultrasound, MRI
Prognostic factor: the ratio of contralateral lung
area to head circumference (LHR)
At birth respiratory difficulties
immediately intubated
Mask bagging is avoided because it increases
the distention of the herniated stomach and
intestine and therefore compromises the
ventilation even more
Stabilization of the patient and delayed surgical
repair is now the standard of care for newborns
with CDH
Gentle ventilation with permissive hypercapnia:
preductal SatO2 >85%, tolerating PaCO2 up to
60mmHg
Inhaled NO, HFOV, ECMO
11. Chandrasekharan PK, Rawat M, Madappa R,
Rothstein DH, Lakshminrusimha S. Congenital
Diaphragmatic hernia - a review. Matern Health
Neonatol Perinatol. 2017;3:6. doi:10.1186/s40748-017-
0045-1
Prenatal
Diagnostic
When? Can be visualized in first
trimester
Detects >50% at 24 weeks
Ultrasound Calculate O/E LHR, position
of liver (intra-abdominal or
intrathoracic)
Other associated anomalies?
Cardiac, renal, CNS, GI
Fetal MRI
Mortality significantly decreased with
advancing gestation; 25 – 36% at 37
weeks, 17 – 20% at 40 weeks
13. Canadian Congenital Diaphragmatic Hernia Collaborative, Puligandla PS, Skarsgard ED, et al. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ. 2018;190(4):E103-E112
14. Canadian Congenital Diaphragmatic Hernia Collaborative, Puligandla PS, Skarsgard ED, et al. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ. 2018;190(4):E103-E112
15. Canadian Congenital Diaphragmatic Hernia Collaborative, Puligandla PS, Skarsgard ED, et al. Diagnosis and management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ. 2018;190(4):E103-E112
16. LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia: Wolters Kluwer, 2019.
17. Should be performed electively, after clinical stabilization
(similar for CDH EURO Consortium Group and Canadian
Congenital Diaphragmatic Hernia Collaborative)
The herniated viscera are returned to the abdomen, and, in
the rare case in which a hernia sac is present, it is excised
Any small diaphragmatic defect is closed with interrupted
nonabsorbable sutures
For larger diaphragmatic defects, or in complete absence of the
hemidiaphragm, a polytetrafluoroethylene (PTFE) membrane
is used and can sometimes be sutured to the ribs anteriorly and
posteriorly
Optimal surgical technique under debate: minimal vs open,
thoracotomy or laparotomy
18.
19. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill
Livingstone, 2008.
Diaphragmatic continuity is
present but the incomplete and
abnormal development of the
muscle leads to an inability to
contract normally
Incomplete migration of myoblasts
from cervical somites into
pleuroperitoneal membrane
CXR: the presence of a
hemidiaphragm at least two
intercostal spaces higher than on
the other side (may be difficult to
observe in ventilated patient)
20. Asymptomatic patients do not require treatment
• The noncontracting part of the diaphragm is folded in a mediolateral direction and
sutured with nonabsorbable sutures
• Care must be taken to avoid injury to the phrenic nerve, or to intra-abdominal
organs if the surgical approach is transthoracic
The aim of surgery is to plicate the hemidiaphragm in a flattened position two
intercostal spaces lower than its initial position
Abdominal approach: bilateral eventration, volvulus, previous cardiac surgery
Minimal invasive: thoracoscopy or laparoscopy
21. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
A
P
P
R
O
A
C
H
E
S
Thoracotomy
Laparotomy
Thoracoabdominal
Incision
VATS/Laparoscopy
22. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
23. Patterson GA (ed.). Pearson's Thoracic and
Esophageal Surgery 3rd edition. Philadelphia:
Churchill Livingstone, 2008.
24.
25. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone, 2008.
Usually found incidentally on routine chest
radiographs in asymptomatic or mildly symptomatic
patients
Most cases of CDH diagnosed in adults are addressed
surgically
• Potential for catastrophic complications secondary to
organ volvulus and perforation
Abdominal approach preferred complete
inspection of the abdominal organs that may have
been injured by incarceration, strangulation, or the
reduction procedure itself
The defect can sometimes be closed primarily without
tension, a polypropylene or polytetrafluoroethylene mesh
is typically used
• Severe dyspnea interfering with normal activities, orthopnea
• Gastrointestinal symptoms clearly related to the high position
of the diaphragm
Treated conservatively unless:
• Simple plication without opening the diaphragm
• Excision of a central ellipse of aponeurotic diaphragm
followed by double breasted suture
Operation: posterolateral approach
• Immobilize the diaphragm in a lower flat position
• Reduce its compression of the ipsilateral lung and
mediastinum
• Possibly to recover function if there is adequate residual
muscle under the costal arch
Objectives:
26. • Congenital diaphragmatic malformations include congenital diaphragmatic hernia (CDH) and
diaphragmatic eventration (DE). The eventrated diaphragm, which is an abnormally thin diaphragm,
results from an abnormal development of its muscular component. It must be differentiated from
diaphragmatic paralysis.
• The standard of care for newborns presenting with CDH is delayed surgical repair after that the patient
has been stabilized. During that time, nitric oxide, high-frequency jet ventilation, and extracorporeal
membrane oxygenation may be used.
• Surgery is rarely needed for DE in the pediatric population. It may be indicated in symptomatic patients or
when a large eventration will potentially interfere with postnatal lung growth.
• An elevated diaphragm in the adult population is attributed to congenital diaphragmatic malformation
only after other etiologies have been excluded. Indications for surgery in adults are rare and are almost
limited to previously unrecognized diaphragmatic hernias. Clinicians must be careful before
recommending diaphragmatic plication for respiratory or digestive symptoms thought to be related to
eventration..
27. Patterson, GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill Livingstone,
2008.
LoCicero III, J (ed.). Shields’ General Thoracic Surgery 8th edition. Philadelphia: Wolters Kluwer, 2019.
Canadian Congenital Diaphragmatic Hernia Collaborative, Puligandla PS, Skarsgard ED, et al. Diagnosis and
management of congenital diaphragmatic hernia: a clinical practice guideline. CMAJ. 2018;190(4):E103-
E112. doi:10.1503/cmaj.170206.
Snoek KG, Reiss IK, Greenough A, et al. Standardized Postnatal Management of Infants with Congenital
Diaphragmatic Hernia in Europe: The CDH EURO Consortium Consensus - 2015 Update. Neonatology.
2016;110(1):66-74. doi:10.1159/000444210
Kardon G, Ackerman KG, McCulley DJ, et al. Congenital Diaphragmatic Hernias: From Genes to Mechanisms to
Therapies. Disease Models & Mechanisms. 2017;10:955-970. doi:10.1242/dmm.028365
Chandrasekharan PK, Rawat M, Madappa R, Rothstein DH, Lakshminrusimha S. Congenital Diaphragmatic hernia - a
review. Matern Health Neonatol Perinatol. 2017;3:6. doi:10.1186/s40748-017-0045-1