Portal hypertension is high blood pressure in the portal vein system that supplies blood to the liver. It has various clinical manifestations that may require surgical management. The surgical approach depends on factors like the underlying liver disease severity and venous anatomy. The main goals of surgery are to decrease portal pressure and prevent complications by bypassing resistance sites or directly treating complications. Procedures include devascularization to reduce variceal blood flow or decompression procedures to reduce portal pressure while maintaining hepatic blood flow. Selective shunts only decompress the variceal compartment while non-selective or partial shunts provide complete or incomplete decompression of the entire portal system. The distal splenorenal shunt is a commonly used selective shunt that
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
Devascularization in portal hypertension.dr quiyumMD Quiyumm
role of surgery in portal hypertension is promising. Devascularization is one of the procedure of choice in unshuntable portal vein. Though LT is treatment of choice
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
Intestinal fistulas pose the greatest challenge to the General Surgeon. The presentation provides abrief guideline for management of this complex problem.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Whipple's procedure - Indications, Steps, ComplicationsVikas V
Whipple's Procedure - Explaining the History of Whipple's Procedure, Indications, Contraindications, Step wise detailed procedure, Complications, Perioperative Management.
The Presentation Includes Detailed Step wise approach to the procedure assisted with Pictorial Representation of The steps
Intestinal fistulas pose the greatest challenge to the General Surgeon. The presentation provides abrief guideline for management of this complex problem.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
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.
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 Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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
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!
9. If bleeding cannot be controlled or endoscopy
delays
Baloon tamponade
• considered a temporary bridge to more definitive measures of
variceal hemorrhage control
• control refractory bleeding in up to 90% of patients
Contraindications:
• History of esophageal strictures
• Recent gastric or esophageal surgeries
11. • Potential for complications:
• aspiration
• airway obstruction
• esophageal perforation due to overinflation or pressure necrosis
Use should not exceed 36 hours to avoid tissue necrosis
13. Transjugular intrahepatic Porto Systemic
shunt (TIPS)
Involves implantation of a metallic
stent
• between an intrahepatic branch of
the portal vein and a hepatic vein
radicle
• The needle track is dilated until a
portal pressure gradient of ≤12
mmHg is achieved.
14. TIPS (contd.)
• TIPS for control of acute variceal bleeding: 93 - 95 %
• 1-month actuarial probability of rebleeding : 22%
• Operative mortality (30 days) : 28%.- 37%
• Complications : 13%
• massive hemoperitoneum
• cardiorespiratory arrest & cardiac failure
• acute renal failure
• bacteremia
Banares R, Am J Gastroenterol. 1998
Bosch J. J Hepatol 2001
15. Contraindications for TIPS
Right heart failure --most significant --acute death from total heart
failure (Peron et al, 2000)
• Older age of patient
• High MELD or Child ough score
• Cavernous transformation
• Polycystic liver disease
• Active spontaneous bacterial peritonitis (SBP)
16. TIPS
Advantage
• Non-operative approach
• Ideal in short term portal
decompression in patient
requiring liver transplant until
donor is available
• Advanced hepatic functional
decompensation who are
unlikely to survive long enough
for TIPS to malfunction
Disadvantage
Shunt stenosis or shunt thrombosis (
upto 50%) within first year
Recurrent portal hypertensive bleeding
Total shunt occlusion in 10-15% of
patients
17. TIPS vs Endoscopic therapy
• Rebleeding = 19 vs 47%
• Encephalopathy = 34% in TIPS
18. TIPS vs Surgery (Distal splenorenal shunt)
Randomised trial
• 73 DSRS & 67 TIPS (Child Pugh A and B patients)
• Follow-up: 2-8yrs
• DSRS and TIPS similar in efficacy in the control of refractory variceal bleeding
• rebleeding : DSRS, 5.5%; TIPS, 10.5%; P = .29
• Re-intervention: significantly greater for TIPS compared with DSR(DSRS, 11% v/s
TIPS, 82%, p<0.001)
• No difference in need for Liver Transplantation
The choice is dependent on available expertise .
Henderson JM, et al, Gastroenterology, May 2006
19. Devascularization procedures
• Reduce blood flow to varices
• Interrupt bleeding source
• Eliminate the complications of
splenomegaly (hypersplenism)
Advantages :
• Easy technique
• Low mortality
• Low recurrent variceal bleeding
rate
• Postoperative encephalopathy is
rare - preserving of portal blood
flow
• Liver function well preserved
21. Hassab operation
• Gastro-esophageal decongestion and
splenectomy
• Perhiatal devascularization of lower
esophagus
• Complete separation of the stomach from
its bed
• Ligation of the left gastric artery at the
lesser curvature, peritonization of greater
curvature and suction drainage of the
splenic bed
23. Indication for surgery
Absolute
• Symptomatic hypersplenism (recurrent
bleeding or infection)
• Severe thrombocytopenia (<10000)
• Symptomatic or medically refractory
hepatic encephalopathy
• Hepatopulmonary syndrome
• Portopulmonary syndrome
Relative
• Symptomatic splenomegaly (pain,rupture,
infarction,restricting daily activities )
• Poor health related QOL
• Large varices with poor access to health
care or rare blood groups
• Refractory LGI bleed due to ano-rectal
varices or colopathy
• Portal biliopathy
• Growth failure
• Delay In sexual development
24. Patient preparation
(1) underlying liver disease and its severity (Child pugh score/ MELD
Score )
(2) abdominal venous anatomy (imaging )
(3) overall performance status
25. Therapeutic goal:
to decrease portal pressure thus prevent and treat PH complications
Aims :
• Bypass the portal resistance site by creating portoportal or, more
commonly, portosystemic shunts (PSS);
• When not feasible, direct treatment of complications of NCPH (eg,
ligation of varices)
29. Decompression procedures
Aim
• Reduce portal venous pressure
• Maintain total hepatic and portal blood flow
• Avoid the high incidence of complicating hepatic encephalopathy
30. Non selective shunts (complete porto systemic
decompression )
decompress the entire portal system by diverting all
portal flow
Portocaval End to side or side to side anastomosis
Mesocaval Side to side or with an interposition graft
Mesoatrial Requires interposition PTFE graft
Proximal splenorenal End to side anastomosis of proximal splenic vein to left
renal vein
Requires splenectomy
Partial (incomplete portal system decompression) Non selective shunt with diameter <10mm
31. Portocaval shunt
First described by Eck in 1877,
• either joins the portal vein to the
IVC in an end-to-side fashion and
completely disrupts portal vein
flow to the liver
• or joins it in a side-to-side fashion
and thereby maintains partial
portal venous flow to the liver.
32. Portocaval shunt
• Help to decrease variceal bleeding
• Refractory ascites treatment
• Decompresses the splanchnic venous
circulation and intrahepatic sinusoid network
• Performed when TIPS not available or fails
Disadvantage
• Rebleeding rate upto 70%
• Encephalopathy 20-40%
• Accelerated hepatic failure due to
decrease in hepatic perfusion
• Makes subsequent hepatic transplantation
much more technically difficult
33. Mesocaval shunt
• Uses an 8- or 10-mm PTFE graft
• connect superior mesenteric vein to the IVC
• Technically easier to perform
• Ease hepatic transplantation.
• Smaller caliber of the shunt :
1. avoids the deleterious effects of portal blood flow
deprivation on hepatic function
2. reduce the incidence of encephalopathy
Disadvantage : increased risks of shunt thrombosis
and rebleeding
36. Mesoatrial shunt
portal vein to drain directly into the right atrium
Use : Budd Chiari syndrome inferior venacava
thrombosis can be present
37. Selective (variceal-bearing compartment
decompression)
decompress only the variceal-bearing compartment of
the portal venous system and preserve some portal flow
to the liver
Inokuchi's left gastric venous caval End to side anastomosis of left gastric vein vena cava,
may require an autologous graft
Splenocaval End-to-side anastomosis of distal splenic vein to cava,
may require an interposition PTFE graft
Small‐diameter H‐graft shunt. PTFE reinforced grafts that measure 8 mm in internal
diameter and connects the superior mesenteric vein or
portal vein to inferior vena cava.
Warren's distal splenorenal End-to-side anastomosis of distal splenic vein to left
renal vein, includes ligation of the coronary and
pancreatic veins
38. Distal Spleno-Renal shunt
• Aka Warren Shunt
• Division of GE collaterals
• End-to-side splenic to left renal vein
anastomosis
• allows venous drainage of the stomach and
lower esophagus through the short
gastrosplenic veins into the spleen
• allowing the splenic vein to drain directly
into the left renal vein
• ultimately decompresses the left LUQ.
Interruption of all collateral vessels
39. Selective shunt- DSRS
Advantages :
• SMV continues to perfuse
liver
• lower rate of hepatic
encephalopathy and
decompensation (<10%)
• not interfering with
subsequent liver
transplantation.
• Rate of recurrent bleeding
(7-13%)
Disadvantages:
• Technically more
demanding
• Important lymphatic
pathways transected-
aggravates ascites
• Gradual collateralizes-
loss of portal flow in
50% in 1year
• Complications : acute
pancreatitis, pseudocyst
• Mortality: 1-19%)
Contraindication
• Prior splenectomy
• Splenic vein <7mm
• Intractable ascites
40. Portoportal shunts
Rex shunt Connects superior mesenteric vein or varix to the left
portal system at the recessus of Rex (left portal vein
system)
41. Rex Bypass
• Direct portal revascularization can be
achieved by interposing a vascular graft
between the SMV and the Rex
recessus (left portal vein system)
• very successful physiologic cure of
chronic portal hypertension and
restores the portal flow into and
through the liver graft.
• Primary revascularization of liver grafts
• Managing early acute portal vein
thrombosis episodes.
42. Selection of shunts procedure
• Depends on hepatic functional reserve
• patency of the splenoportal venous axis
• Patient's transplant candidacy
• Available surgical expertise
- Portal blood containing hormones, nutrients and cerebral toxins
diversion cause adverse reactions
- Portosystemic encephalopathy
- Accelerated hepatic failure
44. Follow up
• Regular 6 monthly follow up to look for spleen size, growth, quality of
life, school performance, development of jaundice, decompensation,
portal biliopathy, hepato-pulmonary syndrome
45. References
• Sabiston textbook of surgery, 20th edition
• Consensus on EHPVO, SK Sarin et al., 2006
• ACG & AASLD Joint Clinical Guideline: Prevention and Management
of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis
Am J Gastroenterol 2007;102:2086–2102
• Non-cirrhotic portal hypertension – Diagnosis and
management.Journal of Hepatology 2014 vol. 60 j 421–441 439