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RGN / Administrator – SABBI R WARD TEL/FAX 01249 783750 GASTROESOPHAGEAL REFLUX DISEASE (HEARTBURN) AND LAPAROSCOPIC NISSEN Gastroesophageal reflux occurs when acid passes upwards (reflux) from the stomach into the gullet (oesophagus). This is caused by a lax muscle valve (sphincter) at the junction of the oesophagus and stomach, failing to close properly. This is frequently associated with having a hiatus hernia, which is when the stomach slips from the abdomen up in to the chest. Acid in the oesophagus causes heartburn, which is characterised by a harsh burning sensation in the upper abdomen and/or chest. In addition there may be chronic cough, wheeze, regurgitation and difficulty in swallowing. Lying down or leaning forward usually worsens acid reflux. Reflux may happen occasionally and be relieved by an antacid such as Gaviscon. In more severe cases it can occur daily and is more difficult to control. Long-term reflux can be associated with complications such as bleeding, anaemia, difficulty in swallowing and increased cancer risk. Losing weight, reducing the amount of fatty, spicy, greasy foods, decaffeinated drinks, smoking and alcohol consumption may all help the symptoms. Specialised drugs called Proton Pump Inhibitors such as Omeprazole, Lansoprazole and Esomeprazole can be prescribed and do help in most cases. Investigation of long-term reflux is essential. The most useful test is gastroscopy, to confirm the presence of reflux, the presence of hiatus hernia and to determine the presence of complications. Other tests such as barium meal and acid studies may be helpful. Until recently surgery was considered a last resort, as it was a major procedure, requiring a large incision, several days in hospital and a painful recovery. Now however, the operation may be carried out using keyhole surgery (laparoscopically). This is called laparoscopic Nissen fundoplication. Five 0.5-1cm incisions are made in the abdomen and used to insert a small camera (laparoscope) and the surgical instruments required to perform the operation. The hiatus hernia is repaired and a new valve is created by wrapping the upper portion of the stomach around the lowest point of the oesophagus to form a collar. This is then stitched (sutured) in place. Finally, the skin sutures, which are dissolvable, are then covered with small dressings. This approach has made the operation much more popular, with increasing numbers of patients seeking keyhole surgery. Following surgery; There may be discomfort around the operation sites. You may feel bloated or constipated for a few days. You may require pain-relieving medication, which should be soluble/non effervescent i.e. Paracetamol There will be small dressings over the operation sites. You may go home once you are able to eat, drink, pass urine and walk around (usually 1/2 days). For the first 2 weeks take mostly a liquid diet gradually increasing this to include small soft meals. Many patients will lose some weight owing to this diet and this is quite expected. Your swallowing will not be normal for at least the first month. Avoiding fizzy drinks is essential to reduce bloating and wind. Exercise as you feel able. If you have a sedentary job it may be possible to return to work after a short time. If your work is physical allow a little longer. The advantages of keyhole surgery are that the operation gives much less discomfort, the stay in hospital is only one to two days, healing is faster, cosmetic results better, and as a result it is possible to resume normal activities sooner. Potential complications In a few patients (1 in 500 cases with Mr Armstrong) laparoscopic surgery is not possible and must be converted to open abdominal surgery. Patients with very large hiatus hernias more frequently need open surgery Damage to intra-abdominal organs (liver, spleen, oesophagus, stomach) is rare and is repaired during surgery. Bleeding during surgery is unusual but might require open surgery. Difficulty with swallowing (dysphagia) may be persistent for several months. The majority of patients recover. A small number (less than 2%) may have persistent problems, which can be avoided by keeping to a soft diet. Gaseousness (gas bloat) may occur in some patients. This usually improves with time and can be helped by keeping off gassy drinks and dietary advice. Recurrence of reflux symptoms is unusual. This can often be treated with medications, although a small number of cases may require further surgery. Mechanical problems with the operation are uncommon (e.g. slipped wrap) but occasionally need further surgery. All surgery carries the risk of heart problems; lung disorders, stroke or blood clots (thrombosis) Steps are taken to reduce these risks before and during surgery. THE MAJORITY OF PATIENTS HAVE UNEVENTFUL LAPAROSCOPIC SURGERY Mr Armstrong is a recognised expert in this type of surgery and has to date performed over 1100 of these procedures, with 0% mortality. He is one of the most experienced surgeons in the United PLEASE GIVE YOUR INSURANCE COMPANY THE FOLLOWING OPERATION CODES

Source: http://www.kitarmstrong.co.uk/care_info/LAPAROSCOPIC%20NISSEN%20INFORMATION.pdf

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Development and validation of an HPLC method to analyze ibuprofen and impurities according to the European Pharmacopoeia Abstract This Application Note describes the development of a fast, accurate,and reproducible method to analyze ibuprofen and related impuritiesaccording to European Pharmacopoeia (EP) regulations1, using anAgilent 1120 Compact LC. The experiments described in thisAp

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