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Ankyloglossia or Tongue -tie

Definition:
By definition, complete ankyloglossia is the total adherence of the tongue to the floor of the mouth. Partial ankyloglossia is incomplete separation of the tongue from the bottom of the mouth due to a short frenulum, which is a fibrous membrane extending from the bottom of the tongue to an area below the bottom front teeth. Tongue-tie can be evident when the baby is crying or by careful inspection.

CLICK TO SEE THE PICTURES…..>….(01)....(1).…..….(2)..……...(3)..……..…………..

List of images in Gray's Anatomy: XII. Surface...

List of images in Gray’s Anatomy: XII. Surface anatomy and Surface Markings (Photo credit: Wikipedia)

Symptoms:
There are certain facial features that have been found to be associated with a short frenulum.

*High-arched palate: characterized by a higher than normal arch of the roof of the mouth.
*Retrognathia: very small chin.
*Micrognathia: a recessed or undefined chin.
*Prognathism: a protruding lower jaw.
*Can’t stick the tongue forward
*Difficulty feeding
*Excessive attachment of tongue to bottom of the mouth
*V-shaped notch in tip of tongue

Causes:
Tongue-tie causes a significant portion of of the problems encountered with breastfeeding. It also is thought to pose other short term and long term complications, such as speech impediments, problems with swallowing, and the formation of teeth arrangement. There is some controversy over the defining characteristics of tongue-tie as well as the treatments.

When we hear the term “tongue-tied”, most of us have a mental image of someone who is struggling to speak in public, but is stammering nervously and is at a loss for words. In reality, tongue-tie is a medical condition that affects many people, and has special implications for the breastfed baby.
The medical term for the condition known as tongue-tie is “ankyloglossia”. It results when the frenulum (the band of tissue that connects the bottom of the tongue to the floor of the mouth) is too short and tight, causing the movement of the tongue to be restricted.
Tongue-tie is congenital (present at birth) and hereditary (often more that one family member has the condition). It occurs relatively often: between 0.2% and 2% of babies are born with tight frenulums.

To tell if your baby is tongue-tied, look at him and stick out your tongue. Even tiny babies will imitate you. If he is unable to extend his tongue fully, or if it has a heart shaped appearance on the tip, then you should have him evaluated by his doctor. You can also try putting your finger in his mouth (pad side up) until he starts sucking. See if his tongue extends over his gum line to cup the bottom of your finger. If not, you may want to have him checked.
In most cases, the frenulum recedes on its own during the first year, and causes no problems with feeding or speech development. A lot depends on the degree of the tongue-tie: if the points of attachment are on the very tip of the tongue and the top ridge of the bottom gum, feeding and speech are more likely to be affected than if the frenulum is attached further back.

Severe tongue-tie can cause problems with speech. Certain sounds are difficult to make if the tongue can’t move freely (especially ‘th’, ‘s’, ‘d’, ‘l’, and ‘t’). In addition to forming specific sounds, tongue-tie may also make it hard for a child to lick an ice cream cone, stick out his tongue, play a wind instrument, or French kiss. While these may not seem like important skills to you as a new mother, someday they may be very important to your child! Dental development may also be affected, with severe tongue- tie sometimes causing a gap between the two lower front teeth.
Of more immediate importance is the negative impact that a tight frenulum can have on a baby’s ability to breastfeed effectively. In order to extract milk from the breast, the baby needs to move his tongue forward to cup the nipple and areola, drawing it back in his mouth and pressing the tissue against the roof of his mouth. This compresses the lactiferous sinuses (the pockets behind the areola where the milk is stored) and allows the milk to move into the baby’s mouth. The tongue plays an important role in breastfeeding, and if the baby’s frenulum is so short that his tongue can’t extend over the lower gum, he may end up compressing the breast tissue between his gums while he nurses, which can cause severe damage to the nipples.
Tongue-tie can cause feeding difficulties such as low weight gain and constant fussiness in the baby. Nursing mothers may experience nipple trauma (the pain doesn’t go away no matter what position is used), plugged ducts, and mastitis.

Some tongue-tied babies are able to nurse effectively, depending on the way the frenulum is attached, as well as the individual variations in the mother’s breast. If the mother has small or medium nipples, the baby may be able to manage to extract the milk quite well in spite of being tongue-tied. On the other hand, if the nipples are large and/or flat, then even a slight degree of tongue-tie may cause problems for a nursing baby.
In addition to problems with nipple soreness and weight gain, some other signs that the baby may be having problems nursing effectively include breaking suction often during feedings, and making a clicking sound while nursing. Since these symptoms can also be caused by other problems, it’s a good idea to be evaluated by a knowledgeable health care provider (a lactation consultant if possible) to rule out causes other than tongue-tie. Tongue-tie should definitely be considered a possibility if breastfeeding doesn’t improve even after other measures such as adjustments in positioning have been tried.
If it is determined that tongue-tie is causing breastfeeding difficulties, there is a simple procedure called a “frenetomy” that can quickly correct the problem. In a relatively painless in-office procedure, the doctor simply clips the frenulum to loosen it and allow the tongue full range of motion. It takes less than a second, and because the frenulum contains almost no blood, there is usually only a drop or two of blood. The baby is put on the breast immediately following the procedure, and the bleeding stops almost instantly. Anesthesia and stitches are not necessary. The baby cries more because he is being restrained for a few seconds that he does because of pain. Comparing the procedure to ear piercing is a good analogy. Both involve a second or two of discomfort and a very small risk of infection, but are overall very safe and simple procedures.

Diagnosis
According to Horton et al., diagnosis of ankyloglossia may be difficult; it is not always apparent by looking at the underside of the tongue but is often dependent on the range of movement permitted by the genioglossus muscles. For infants, passively elevating the tongue tip with a tongue depressor may reveal the problem. For older children, making the tongue move to its maximum range will demonstrate the tongue tip restriction. In addition, palpation of genioglossus on the underside of the tongue will aid in confirming the diagnosis.

In most cases, the mother notices an immediate improvement in both her comfort level and the baby’s ability to nurse more efficiently. If the tongue-tie isn’t identified and the frenulum isn’t clipped until the baby is several weeks or months old, then it may take longer for him to learn to suck normally. Sometimes suck training is necessary in order for him to adapt to the new range of motion of his tongue. If tongue-tie is causing severe breastfeeding difficulties, then the sooner the frenulum is clipped, the better. Sometimes children end up having the procedure done when they are much older, because the problem isn’t identified until after they begin developing significant speech problems.

Even though clipping the frenulum is a simple, safe, and uncomplicated procedure, it may be difficult to find a doctor who is willing to perform it. The history of treating tongue-tie is somewhat controversial. Up until the nineteenth century, baby’s frenulums were clipped almost routinely. Because of the potential for feeding and speech problems, midwives were reported to keep one fingernail sharpened so that they could sweep under the tongue and snip the frenulum of just about all newborn babies. Any procedure that involves cutting tissue in the mouth can potentially involve infection or damage to the tongue, especially back in the days before sterile conditions and antibiotics. Because the procedure was overdone and in most cases, wasn’t really necessary, doctors became very reluctant to clip frenulums at all and the procedure was rarely performed.

Part of the reason frenotomies fell out of favor for many years was the fact that doctors discovered that in all but the most severe cases, speech was not affected by tongue-tie. They preferred to take a “wait and see” approach and let nature take it’s course. Most of the time, the frenulum would stretch out on its own with no intervention.

During the same time period that frenotomies were becoming less common, the rate of breastfeeding also declined dramatically. Bottle-feeding doesn’t present the same feeding difficulties for tongue-tied babies that breastfeeding does, because the mechanics are very different and extension of the tongue doesn’t play as big a role in feeding from the bottle. Since the majority of babies were bottle fed, it was easy for doctors to say that they weren’t going to perform an unnecessary procedure that didn’t interfere with feeding, and rarely caused speech problems.
Even today, with most infants in this country starting out breastfeeding, it may be difficult to find a doctor who recognizes the problem that tongue-tie can present for a nursing baby and is willing to perform a frenotomy. The procedure is seldom mentioned in the pediatric literature, and is no longer routinely taught in medical school.

If you feel that your baby’s breastfeeding difficulties may be due to tongue-tie, you may need to work at finding a health care provider who can diagnose the problem and clip the frenulum. Although any pediatrician or general family practitioner can theoretically perform a frenotomy, many prefer to make a referral to an oral surgeon, dentist, or ENT specialist.

Diagnosis of Clinically Significant Tongue-Tie
Based on a combination of anatomical appearance and functional disturbance:

Anatomical Type I: Frenulum attaches to tip of tongue in front of alveolar ridge in low lip sulcus….

Type II: Attaches 2-4mm behind tongue tip and attaches on alveolar ridge…..click for picture.

Type III: Attaches to mid-tongue and middle of floor of the mouth, usually tighter and less elastic. The tip of the tongue may appear “heart-shaped”

Type IV: Attaches against base of tongue, is shiny, and is very inelastic

CLICK & SEE THE PICTURES

Effects:-
Ankyloglossia can affect feeding, speech, and oral hygiene   as well as have mechanical/social effects.   Ankyloglossia can also prevent the tongue from contacting the anterior palate. This can then promote an infantile swallow and hamper the progression to an adult-like swallow which can result in an open bite deformity.   It can also result in mandibular prognathism; this happens when the tongue contacts the anterior portion of the mandible with exaggerated anterior thrusts.    The authors sent a survey to a total of 1598 otolaryngologists, pediatricians, speech-language pathologists and lactation consultants with questions to ascertain their beliefs on ankyloglossia; 797 of the surveys were fully completed and used in the study. It was found that 69 percent of lactation consultants but only a minority of pediatricians answered that ankyloglossia is frequently associated with feeding difficulties; 60 percent of otolaryngologists and 50 percent of speech pathologists answered that ankyloglossia is sometimes associated with speech difficulties compared to only 23 percent of pediatricians; 67 percent of otolaryngologists compared to 21 percent of pediatricians answered that ankyloglossia is sometimes associated with social and mechanical difficulties. Limitations of this study include a reduced sample size due to unreturned or incomplete surveys.

Feeding
Messner et al. studied ankyloglossia and infant feeding. Thirty-six infants with ankyloglossia were compared to a control group without ankyloglossia. The two groups were followed for six months to assess possible breastfeeding difficulties, defined as nipple pain lasting more than six weeks, or infant difficulty latching onto or staying onto the mother’s breast. Twenty-five percent of mothers of infants with ankyloglossia reported breast feeding difficulty compared with only 3 percent of the mothers in the control group. The study concluded that ankyloglossia can adversely affect breastfeeding in certain infants. Infants with ankyologlossia do not, however, have such big difficulties when feeding from a bottle.  Limitations of this study include the small sample size and the fact that the quality of the mother’s breast feeding was not assessed.

Wallace and Clark also studied breastfeeding difficulties in infants with ankyloglossia.[8] They followed 10 infants with ankyloglossia who underwent surgical tongue tie division. Eight of the ten mothers experienced poor infant latching onto the breast, 6/10 experienced sore nipples and 5/10 experienced continual feeding cycles; 3/10 mothers were exclusively breastfeeding. Following a tongue tie division, 4/10 mothers noted immediate improvements in breastfeedings, 3/10 mothers did not notice any improvements and 6/10 mothers continued breastfeeding for at least four months after the surgery. The study concluded that tongue tie division may be a possible benefit for infants experiencing breastfeeding difficulties due to ankyloglossia and further investigation is warranted. The limitations of this study include that the sample size was small and that there was not a control group. In addition, the conclusions were based on subjective parent report as opposed to objective measures.

Speech
Messner and Lalakea studied speech in children with ankyloglossia. They noted that the phones likely to be affected due to ankyloglossia include sibilants and lingual sounds such as [t d z s ? ð n l]. In addition, the authors also state that it is uncertain as to which patients will have a speech disorder that can be linked to ankyloglossia and that there is no way to predict at a young age which patients will need treatment. The authors studied 30 children from one to 12 years of age with ankyloglossia, all of whom underwent frenuloplasty. Fifteen children underwent speech evaluation before and after surgery. Eleven patients were found to have abnormal articulation before surgery and nine of these patients were found to have improved articulation after surgery. Based on the findings, the authors concluded that it is possible for children with ankyloglossia to have normal speech in spite of decreased tongue mobility. However, according to their study, a large percent of children with ankyloglossia will have articulation deficits that can be linked to tongue tie and these deficits may be improved with surgery. The authors also note that ankyloglossia does not cause a delay in speech or language but, at the most, problems with enunciation. Limitations of the study include a small sample size as well as a lack of blinding of the speech-language pathologists who evaluated the subjects’ speech.

Messner and Lalakea also examined speech and ankyloglossia in another study. They studied 15 patients and speech was grossly normal in all of the subjects. However, half of the subjects reported that they thought that their speech was more effortful than other peoples’ speech.

Horton et al. discussed the relationship between ankyloglossia and speech. The authors believe that tongue tie contributes to difficulty in range and rate of articulation and that compensation is needed. Compensation at its worst, the article states, may involve a Cupid’s bow of the tongue.

While the tongue tie exists, and even years after removal, common speech abnormalities include mispronunciation of words. The most common is pronouncing Ls as Ws; for example the word “lemonade” would come out as “wemonade.”

Mechanical/Social

Ankyloglossia can result in mechanical and social effects. Lalakea and Messner studied 15 people, aged 14 to 68 years. The subjects were given questionnaires in order to assess functional complaints associated with ankyloglossia. Eight subjects noted one or more mechanical limitations which included cuts or discomfort underneath the tongue and difficulties with kissing, licking one’s lips, eating an ice cream cone, keeping one’s tongue clean and performing tongue tricks. In addition, seven subjects noted social effects such as embarrassment and teasing. The authors concluded that this study confirmed anecdotal evidence of mechanical problems associated with ankyloglossia and that it suggests that the kinds of mechanical and social problems noted may be more prevalent than previously thought. Furthermore, the authors note that some patients may be unaware of the extent of the limitations they have due to ankyloglossia since they have never experienced normal tongue range. A limitation of this study is the small sample size that also represented a large age range.

Lalakea and Messner note that mechanical and social effects may occur even without other problems related to ankyloglossia such as speech and feeding difficulties. Also, mechanical and social effects may not arise until later in childhood as younger children may be unable to recognize or report the effects. In addition, some problems may not come about until later in life, such as kissing.

Complications

The complications are rare, but recurrence of tongue tie, tongue swelling, bleeding, infection, and damage to the ducts of the salivary glands may occur.

Treatment:
Surgery is seldom necessary but if it is needed, it involves cutting the abnormally placed tissue. If the child has a mild case of tongue tie, the surgery may be done in the doctor’s office. More severe cases are done in a hospital operating room. A surgical reconstruction procedure called a z-plasty closure may be required to prevent scar tissue formation.

Prognosis:
Surgery, if performed, is usually successful.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://tonguetie.ballardscore.com/
http://www.breastfeeding-basics.com/html/tonguetie.shtml
http://en.wikipedia.org/wiki/Ankyloglossia
http://www.righthealth.com/topic/Tongue_Tie_Treatment/overview/adam20?fdid=Adamv2_001640&section=Full_Article

http://www.blueskydentaloffice.com/Children_s_Dentistry.html

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Hysteroscopy

Definition:
Hysteroscopy is the inspection of the uterine cavity by endoscopy. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention (operative hysteroscopy).
……………....CLICK & SEE
The hysteroscope is a long tube, about the size of a straw, which has a built-in viewing device. Hysteroscopy is useful for diagnosing and treating some problems that cause infertility, miscarriages, and abnormal menstrual bleeding. Sometimes other procedures, such as laparoscopy, are done at the same time as hysteroscopy.

Method:-
The hysteroscope is an optical instrument connected to a video unit with a fiber optic light source, and to the channels for delivery and removal of a distention medium. The uterine cavity is a potential cavity and needs to be distended to allow for inspection. Thus during hysteroscopy either fluids or CO2 gas is introduced to expand the cavity. The choice is dependent on the procedure and the patient’s condition. Fluids can be used for both diagnostic and operative procedures. However, CO2 gas does not allow the clearing of blood and endometrial debris during the procedure, which could make the imaging visualization difficult. Gas embolism may also arise as a complication. Since the success of the procedure is totally depending on the quality of the high-resolution video images in front of surgeon’s eyes, CO2 gas is not commonly used as the distention medium. Electrolytic solutions include normal saline and lactated Ringer’s. Current recommendation is to use the electrolytic fluids in diagnostic cases, and in operative cases in which mechanical, laser, or bipolar energy is used. Since they are conducting electricity, these fluids should not be used with monopolar electrosurgical devices. Non-electrolytic fluids eliminate problems with electrical conductivity, but can increase the risk of hyponatremia. These solutions include glucose, glycine, dextran (Hyskon), mannitol, sorbitol and a mannitol/sorbital mixture (Purisol). Water was once used routinely, however, problems with water intoxication and hemolysis discontinued its use by 1990. Each of these distention fluids is associated with unique physiological changes that should be considered when selecting a distention fluid. Glucose is contraindicated in patients with glucose intolerance. Sorbitol metabolizes to fructose in the liver and is contraindicated if patients has fructose intolerance. High-viscous Dextran also has potential complications which can be physiological and mechanical. It may crystallize on instruments and obstruct the valves and channels. Coagulation abnormalities and adult respiratory distress syndrome (ARDS) have been reported. Glycine metabolizes into ammonia and can cross the blood brain barrier, causing agitation, vomiting and coma. Mannitol 5% should be used instead of glycine or sorbitol when using monopolar electrosurgical devices. Mannitol 5% has a diuretic effect and can also cause hypotension and circulatory collapse. The mannitol/sorbitol mixture (Purisol) should be avoided in fructose intolerant patients.

A hysteroscope is in fact a modification of the traditional resectoscope, which is used for transurethral resection of the prostate. It has a double-channeled sheath allowing for continuous flow of fluid or gas media into the uterus through the larger channel, while allowing for less outflow through the smaller channel. This results in the distention of the uterine cavity. With modern optical technologies, hysteroscopes are getting smaller in diameter yet able to provide larger and brighter images for surgeons’ convenience.

After cervical dilation, the hysteroscope is guided into the uterine cavity and an inspection is performed. If abnormalities are found, an operative hysteroscope with a channel to allow specialized instruments to enter the cavity is used to perform the surgery. Typical procedures include endometrial ablation, submucosal fibroid resection, and endometrial polypectomy. Typically hysteroscopic intervention is done under general endotracheal anesthesia or Monitored Anesthesia Care (MAC), but a short diagnostic procedure can be performed in a gynecologist‘s office with just a paracervical block using the Lidocaine injection in the upper part of the cervix.

Why it is Done:
Hysteroscopy is useful in a number of uterine conditions:

Asherman’s syndrome (ie. intrauterine adhesions). Hysteroscopic adhesiolysis is the technique of lysing adhesions in the
*uterus using either microscissors (recommended) or thermal energy modalities. Hysteroscopy can be used in conjunction with laparascopy or other methods to reduce the risk of perforation during the procedure.
*Endometrial polyp. Polypectomy.
*Gynecologic bleeding
*Uterine fibroids. Myomectomy.
*Congenital Uterine malformations (also known as Mullerian malformations). Eg.septum,
*Evacuation of retained products of conception in selected cases.

Hysteroscopy has the benefit of allowing direct visualization of the uterus, thereby avoiding or reducing iatrogenic trauma to delicate reproductive tissue which may result in Asherman’s syndrome.
How do you prepare for the test
The time that you schedule this test can be important. Your gynecologist is able to get the best view of the uterine lining during the week that follows your period. If you have regular cycles, it is helpful for you to anticipate the timing of your next period and plan to have the hysteroscopy done in the following week.

Tell your doctor ahead of time if you have ever had an allergic reaction to lidocaine or the numbing medicine used at the dentist’s office. Discuss different options for anesthesia with your doctor in advance.

If your doctor plans on giving you any anti-anxiety medicines before the procedure, or if you are going to have other tests done at the same time as hysteroscopy, you might be told not to eat or drink for eighthours or more before the test. Just before the test, you should empty your bladder.

Risk Factors:

After the procedure, you may have slight vaginal bleeding and cramps for one or two days. Sometimes a small amount of the gas used to expand the uterus can float up to the top of the abdomen and remain there for a day or two before it dissolves away. This can cause some shoulder pain. Some patients experience nausea from medicines used for anesthesia or anxiety.

Some of the procedures that are done along with hysteroscopy have risks of their own. You should ask your doctor about special risks that might come along with additional procedures planned for you.

A common problem is the uterine perforation when the instrument breaches the wall of the uterus. This can lead to bleeding and damage to other organs. A life-threatening condition is the bowel perforation by the instruments after the uterine perforation, resulting in acute peritonitis which can be fatal. Furthermore, cervical laceration, intrauterine infection (especially in prolonged procedures), electrical and laser injuries, and complications caused by the distention media described above are also not uncommon. The overall complication rate for diagnostic and operative hysteroscopy is 2% with serious complications occurring in less then 1% of cases.

How long is it before the result of the test is known
Your doctor can tell you what was seen through the hysteroscope right away. If a biopsy sample is removed, the analysis might take several days.

Resources:
https://www.health.harvard.edu/fhg/diagnostics/hysteroscopy.shtml
http://en.wikipedia.org/wiki/Hysteroscopy

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Bedsore

Definition:
Over one million are afflicted with this life-threatening woundevery year, destroying tissue,fat, muscle, and infecting bone.
Caused by pressure on bony prominences that blocks flow of blood through capillaries

CLICK & SEE.

A pressure-induced ulceration of the skin occurring in persons confined to bed for long periods of time. Also called decubitus ulcer, pressure sore.

Bedsores, more properly known as pressure ulcers or decubitus, are lesions caused by unrelieved pressure to any part of the body, especially portions over bony or cartilaginous areas. Although completely treatable if found early, without medical attention, bedsores can become life-threatening.

Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure — usually from a bed or wheelchair — cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies.

Although people living with paralysis are especially at risk, anyone who is bedridden, uses a wheelchair or is unable to change positions without help can develop bedsores.

Bedsores can develop quickly, progress rapidly and are often difficult to heal. Yet health experts say many of these wounds don’t have to occur. Key preventive measures can maintain the skin’s integrity and encourage healing of bedsores.

Signs and symptoms:
The definitions of the four pressure ulcer stages are revised periodically by the National Pressure Ulcer Advisory Panel (NPUAP) in the United States. Briefly, however, they are as follows:

  • Stage I. Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
  • Stage II. At this point, some skin loss has already occurred — either in the epidermis, the outermost layer of skin, in the dermis, the skin’s deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
  • Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
  • Stage IV. In the most serious and advanced stage, a large-scale loss of skin occurs, along with damage to muscle, bone, and even supporting structures such as tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
  • CLICK & SEE

If you use a wheelchair, you’re most likely to dvelop a pressure sore on:

  • Your tailbone or buttocks
  • Your shoulder blades and spine
  • The backs of your arms and legs where they rest against the chair

When you’re bed-bound, pressure sores can occur in any of these areas:

  • The back or sides of your head
  • The rims of your ears
  • Your shoulders or shoulder blades
  • Your hipbones, lower back or tailbone
  • The backs or sides of your knees, heels, ankles and t

*Unstageable pressure ulcers are covered with dead cells, or eschar and wound exudate, so the depth cannot be determined.

With higher stages, healing time is prolonged. While about 75% of Stage II ulcers heal within eight weeks, only 62% of Stage IV pressure ulcers ever heal, and only 52% heal within one year. It is important to note that pressure ulcers do not regress in stage as they heal. A pressure ulcer that is becoming shallower with healing is described in terms of its original deepest depth (e.g., healing Stage II pressure ulcer).

Etiology:
Bedsores are accepted to be caused by three different tissue forces:

Pressure, or the compression of tissues. In most cases, this compression is caused by the force of bone against a surface, as when a patient remains in a single decubitus position for a lengthy period. After an extended amount of time with decreased tissue perfusion, ischemia occurs and can lead to tissue necrosis if left untreated in an immunocompromised patient.
Shear force, or a force created when the skin of a patient stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also cause the pinching off of blood vessels which may lead to ischemia and tissue necrosis.
Friction, or a force resisting the shearing of skin. This may cause excess shedding through layers of epidermis.
Aggravating the situation may be other conditions such as excess moisture from incontinence, perspiration or exudate. Over time, this excess moisture may cause the bonds between epithelial cells to weaken thus resulting in the maceration of the epidermis. Other factors in the development of bedsores include age, nutrition, vascular disease, diabetes mellitus, and smoking, amongst others.

There are currently two major theories about the development of pressure ulcers. The first and most accepted is the deep tissue injury theory which claims that the ulcers begin at the deepest level, around the bone, and move outward until they reach the epidermis. The second, less popular theory is the top-to-bottom model which says that skin first begins to deteriorate at the surface and then proceeds inward.

Causes:
Many people shift in their chair during meetings, fiddle with the radio when driving, turn a dozen times in their sleep. Every day, without thinking, they make hundreds of subtle postural adjustments that help stave off problems arising from inactivity. But for people immobilized by paralysis, injury or illness, those problems — including bedsores — are a constant threat.

Pressure sores usually result from sustained pressure on your body. They’re especially common in areas that aren’t well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur.

In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off — even perspiration, which can soften skin, making it more vulnerable to injury.

Other causes of pressure sores include:

  • Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores.
  • Shear. This occurs when your skin moves in one direction, and the underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile.

Pathophysiology:
Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open and become infected. Moist skin is more sensitive to tissue ischemia and necrosis and is also more likely to get infected.

Epidemiology
Within acute care, the incidence of bedsores is 0.4% to 38%; within long-term care, 2.2% to 23.9%; and in home care, 0% to 17%. There is the same wide variation in prevalence: 10% to 18% in acute care, 2.3% to 28% in long-term care, and 0% to 29% in home care. There is a much higher rate of bedsores in intensive care units because of immunocompromised individuals, with 8% to 40% of ICU patients developing bedsores.

The risk of developing bedsores can be determined by using the Braden Scale for Predicting Pressure Ulcer Risk. This scale is divided into six risk categories:

sensory perception
moisture
activity
mobility
nutrition
friction and shear
The best possible interpretation is a score of 23 whilst the worst is a 6. If the total score is below 11, the patient is at risk for developing bedsores.

Screening and diagnosis:
Bedsores are usually unmistakable, even in the initial stages, but your doctor is likely to order blood tests to check your nutritional status and overall health. Depending on the circumstances, you may have other tests, including:

  • Urine analysis and culture. A sample of your urine may be examined for various reasons, but you’re especially likely to have this test if you have a problem with incontinence. The test also checks for kidney problems and urinary tract infections, which may be a particular concern for people with spinal cord injuries.
  • Stool culture. In cases of fecal incontinence, a sample of your stool may be sent to a laboratory for analysis.
  • Biopsy. When you have a wound that doesn’t improve, even with intensive treatment, or you have chronic pressure sores, your doctor may remove a small sample of tissue that allows for a complete bacterial evaluation. The tissue may also be checked for cancer, which is a risk in people with long-standing wounds.

Treatment:
The most important thing to keep in mind about the treatment of bedsores is that the most optimal outcomes find their roots in a multidisciplinary approach; by using a team of specialists, there is a better chance that all bases will be covered in treatment.

There are six major contributors to healing.:-

Debridement:
The removal of necrotic tissue is an absolute must in the treatment of pressure sores. Because dead tissue is an ideal area for bacteria growth, it has the ability to greatly compromise wound healing. There are at least seven ways to excise necrotic tissue.

Autolytic debridement is the use of moist dressings to promote autolysis with the body’s own enzymes. It is a slow process, but mostly painless.
Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria. Although this fell out of favour for many years, in January 2004, the FDA approved maggots as a live medical device.
Chemical debridement, or enzymatic debridement, is the use of prescribed enzymes that promote the removal of necrotic tissue.
Mechanical debridement is the use of outside force to remove dead tissue. A quite painful method, this involves the packing of a wound with wet dressings that are allowed to dry and then are removed. This is also unpopular because it has the ability to remove healthy tissue in addition to dead tissue. Lastly, with Stage IV ulcers, there is the chance that overdrying of the dressings can lead to bone fractures and ligament snaps.
Sharp debridement is the removal of necrotic tissue with a scalpel or similar instrument.
Surgical debridement is the most popular method, as it allows a surgeon to quickly remove dead tissue with little pain to the patient.
Ultrasound-assisted wound therapy is the use of ultrasound waves to separate necrotic and healthy tissue.

Infection control:
Infection has one of the greatest effects on the healing of a wound. Purulent discharge provides a breeding ground for excess bacteria, a problem especially in the immunocompromised patient. Symptoms of systemic infection include fever, pain, erythema, oedema, and warmth of the area, not to mention purulent discharge. Additionally, infected wounds may have a gangrenous smell, be discoloured, and may eventually exude even more pus.

In order to eliminate this bioburden, it is imperative to apply antiseptics and antimicrobials at once. It is not recommended to use hydrogen peroxide for this task as it is difficult to balance the toxicity of the wound with this. New dressings have been developed that have cadexomer iodine and silver in them, and they are used to treat bad infections. Duoderm can be used on smaller wounds to both provide comfort and protect them from outside air and infections.

It is not recommended to use systemic antibiotics to treat infection of a bedsore, as it can lead to bacterial resistance.

Nutritional support:
Upon admission, the patient should have a consultation with a dietitian to determine the best diet to support healing, as a malnourished person does not have the ability to synthesize enough protein to repair tissue. The dietitian should conduct a nutritional assessment that includes a battery of questions and a physical examination. If malnourishment is suspected, lab tests should be run to check serum albumin and lymphocyte counts. Additionally, a bioelectric impedance analysis should be considered.

If the patient is found to be at risk for malnutrition, it is imperative to begin nutritional intervention with dietary supplements and nutrients including, but not limited to, arginine, glutamine, vitamin A, vitamin B complex, vitamin E, vitamin C, magnesium, manganese, selenium and zinc. It is very important that intake of these vitamins and minerals be overseen by a physician, as many of them can be detrimental in incorrect dosages.

How to properly care for a bedsore:
The most important care for a patient with bedsores is the relief of pressure. Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound. Nursing homes and hospitals usually set programs to avoid the development of bedsores in bedridden patients such as using a standing frame to reduce pressure and ensuring dry sheets by using catheters or impermeable dressings. For individuals with paralysis, pressure shifting on a regular basis and using a cushion featuring pressure relief components can help prevent pressure wounds.

Pressure-distributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. However, methods to evaluate the efficacy of these products have only been developed in recent years.

Educating the caregiver
In the case that the patient will be returning to home care, it is very important to educate the family about how to treat their loved one’s pressure ulcers. The cross-specialisation wound team should train the caregiver in the proper way to turn the patient, how to properly dress the wound, how to properly nourish the patient, and how to deal with crisis, among other things.

As this is a very difficult undertaking, the caregiver may feel overburdened and depressed, so it may be best to bring in a psychological consult.

Wound intervention:
Once the patient has reached the point that intervention is possible, there are many different options. For patients with Stages I and II ulcers, the wound care team should use guidelines established by the American Medical Directors Association (AMDA) for the treatment of these low-grade sores.

For those with Stage III or IV ulcers, most interventions will likely include surgery such as a tissue flap, skin graft or other closure methods. A more recent intervention is Negative Pressure Wound Therapy, which is the application of topical negative pressure to the wound. This technique, developed by scientists at Wake Forest University, uses foam placed into the wound cavity which is then covered in a film which creates an airtight seal. Once this seal is established, the technician is able to remove exudate and other infectious materials in addition to aiding the body produce granulation tissue, the best bed for the creation of new skin.

There are, unfortunately, contraindications to the use of negative pressure therapy. Most deal with the unprepared patient, one who has not gone through the previous steps toward recovery, but there are also wound characteristics that bar a patient from participating: a wound with inadequate circulation, a raw debridled wound, a wound with necrotised tissue and eschar, and a fibrotic wound.

After Negative Pressure Wound Therapy, the patient should be reevaluated every two weeks to determine future therapy.

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Complications:
Pressure sores can trigger other ailments, and cause patients considerable suffering and financial cost. Some complications include autonomic dysreflexia, bladder distension, osteomyelitis, pyarthroses, sepsis, amyloidosis, anemia, urethral fistula, gangrene and very rarely malignant transformation. Sores often recur because patients do not follow recommended treatment or develop seromas, hematomas, infections, or dehiscence. Paralytic patients are the most likely people to have pressure sores recur. In some cases, complications from pressure sores can be life-threatening. The most common causes of fatality stem from renal failure and amyloidosis.

Risk Factors:
If you’re immobilized by acute illness, injury or sedation — even for a brief time such as after an operation or accident — you can develop pressure sores. But people living with spinal cord injuries are at greatest risk.

Because the nerve damage from these injuries is often permanent, compression of skin and other tissues is ongoing. Exacerbating the problem are thinning or atrophied skin and decreased circulation, both of which make tissue damage more likely and healing more difficult. And because spinal cord injuries reduce or eliminate sensation, you don’t receive the body signals that tell you to shift your position or that a sore is developing.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
www.mayoclinic.com
http://en.wikipedia.org/wiki/Bed_sore

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Cabbage Leaves for Breast Engorgement

 

Your milk has come in and boy do you know it! Perhaps your breasts are so hard and tender your baby can not latch to nurse. Perhaps expressing by hand or pump is not working either. You may be at the point where you will try whatever is available for some relief. It’s time to try Cabbage Leaves. The theory is that there is some chemical in cabbage leaves that reduces milk supply. Research is scant in this area and it isn’t conclusive that cabbage leaves are a miracle cure for engorgement. However there are no harmful effects if used correctly and many women have found them to be very helpful. Cabbage leaves, with the help of your infant nursing frequently (every 2-3 hours), might be the answer for you.Uses for Cabbage Leaves

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  • Local engorgement for specific areas (for example those horrible armpit lumps without other areas of engorgement)
  • Milk engorgement
  • Venous engorgement
  • Suppression of lactation for any reason

 

 

How to use Cabbage Leaves

 

  • Sources state that green, ordinary (not Japanese, etc.) cabbage is preferable.
  • Do not use cabbage leaves if you have an allergy or sensitivity to cabbage (or broccoli, cauliflower or brussell sprouts for that matter). If a rash appears, immediately discontinue using cabbage leaves and call your health care provider.
  • Be warned – there might be a strong odor of cooked cabbage leaves!
  • Wash the leaves thoroughly.
  • The veins can be crushed or removed to allow them to be more form fitting to the breast.
  • They can be chilled in the refrigerator as some feel they are more soothing cold,but it is not necessary.
  • Place in a bra, wrapped around the breast with the nipple exposed.
  • Leave on for 2 hours or until wilted and change to fresh leaves if you need to.
  • Check to see how your breasts are responding with each change and stop using the leaves once engorgement is reduced-prolonged use after engorgement has subsided carries the risk of suppressing your milk production.

 

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(extracted from:http://www.midwifeinfo.com/content/view/51/40/)

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