This rapid clinical improvement is not ...

>> << Endoscopic Retrograde Cholangiopancreatography (ERCP) is widely used diagnostic and therapeutic method in the management of biliary tract and pancreas. Some complications of the procedure, although rare, can have significant morbidity and mortality risks. We describe a case of 68-year old woman who received elective ERCP to clear duct stones. Immediately postprocedure, the patient developed subcutaneous emphysema and bilateral pneumothorax.

Further images showed the presence of free intraabdominal air. The patient made a rapid recovery after bilateral insertion chest drain and no intervention is required. We believe that pneumothorax, subcutaneous emphysema and pnevmomediastinuma at ERCP in the absence of perforation of the duodenum can be attributed to air leakage from the low resistance, such as sphincterotomy site, or by Valsalva maneuver is performed abundant patient tolerance procedure poorly. A. Introduction

ERCP is widely used diagnostic and therapeutic method in the management of biliary tract and pancreas. Some complications of the procedure, although rare, can have significant morbidity and mortality risk [

]. We describe a lasix generic rare case of bilateral pneumothorax complicating ERCP in the presence of abdominal extraluminal air. 2. Case Presentation

68-year-old patient was accepted as an elective patient duct stone clearance under midazolam sedation. Previous extraction failed due to the size of stones while sphincterotomy with biliary stent was performed. Repeated ERCP, sphincterotomy was extended and the two calculations have been removed. Immediately postprocedure, the patient became profoundly hypoxic and tachypnoeic. Medical examination revealed large subcutaneous emphysema and poor air entry bilaterally. The patient was transferred to the HDU, where chest X-ray revealed large bilateral pneumothorax and pnevmomediastinuma (Fig.

). Abdominal imaging (X-ray) showed evidence of further lumen air pneumoperitoneum and pneumoretroperitoneum. The patient was stabilized with bilateral chest drain insertion and made a rapid recovery (Fig.

). Treatment with antibiotics is required, except for one unit, which is empirically introduced immediately after the procedure. On the third day of admission, pneumothorax completely resolved (Fig.

) and chest drains were removed. The patient was discharged the next day. 3. Case Discussion

Only three cases of bilateral pneumothorax complicating ERCP are described in the literature []. Unilateral pneumothorax, though rare, has been described in several cases. In all previous reports, the presence of air in the pleural cavity is accompanied by pneumoperitoneum, pneumoretroperitoneum and pnevmomediastinuma. The proposed mechanism of leakage air clearance by keeping track of the retroperitoneal space in the abdominal cavity, pleural cavity, mediastinum and subcutaneous tissue. Distribution of air is possible through the deep fascial planes [

], but the porous diaphragm syndrome also has been described recently [

]. The most common reason for leakage of air in the lumen ERCP is duodenal perforation [

], but any site with a low resistance, as an ulcer or tumor can serve as a valve during insufflation. [

]. Three different types of ERCP-related perforations are described: (a) conductor associated perforation, (b) periampullary perforation during sphincterotomy, and (c) perforation, distant from the papilla [

]. The above pathophysiological mechanisms may explain the totality of symptoms and the results described in this case as a result vnutryprosvetnoho air escaping into the abdomen. The process underlying issue vnutriprosvetnyy air can be explained by the clinical picture. The patient made a surprisingly quick recovery after chest drain insertion and remained completely asymptomatic until discharge. Only one dose of antibiotics administered. Pneumothorax pnevmomediastinuma, pneumoretroperitoneum and pneumoperitoneum was fully resolved on the third day of admission without further intervention. This rapid clinical improvement would not be expected in case of perforation of duodenum in the duodenoscope. In most cases perforation after ERCP, distant from the nipple (esophagus, stomach, duodenum), require surgical intervention. All cases were symptomatic and required antibiotics [

]. Based on clinical presentation and limited regards the patient, who refused to cross tomography esophagus, stomach or duodenal ulcer perforation was excluded on the basis of clinical picture. Although no additional imaging was obtained due to limitations case, we believe that the investigation of choice to exclude perforation will be crossing the imaging study of the abdominal cavity, which should always be part of the diagnostic in such cases, when possible. Rapid clinical improvement of the patient may be better explained by a small air leak arising from the site of low resistance, which in this case is likely to be sphincterotomy site or conductor associated perforation. However, we note that most reported cases of sphincterotomy or guide related perforation is symptomatic and require broad-spectrum antibiotics, biliary tract and duodenal decompression [,,,

]. There is a second possible explanation for the mechanism that leads to patient presentation and results. This is based on our clinical observations during the procedure. In leakage sphincterotomy after onset of symptoms, is expected to be severe, but gradually over several minutes as the air gradually migrates from the abdominal cavity in the chest. However, in the case described here, and subcutaneous emphysema and pneumothorax seen hyperacutely more seconds. In the previous period, the patient really wanted to exaggerated reactions of respiratory and continuous vomiting during the procedure. We believe that patient response was equivalent to an intensive and continuous Valsalva maneuver. Valsalva was closely associated with the development of subcutaneous emphysema hiperostroy, pnevmomediastinuma, rarely pneumothorax [

]. We believe that the air escape in the mediastinum and pleural space may use the same way as described above, through the deep fascial planes or diaphragmatic pores migrate in the abdomen, explaining the presence of extraluminal air. Clinically, the patient will be represented by a combination of subcutaneous emphysema, pneumothorax, pnevmomediastinuma, pneumoretroperitoneum and pneumoperitoneum. 4. Conclusion >> << Combining our observations with previously existed theory, we believe that pneumothorax, pnevmomediastinuma, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema during ERCP in the absence of perforation of the duodenum, can be explained by leakage of air from the low resistance such as sphincterotomy site or by Valsalva maneuvers performed abundant patient tolerated the procedure poorly. .

This study randomized women who like to

Labels on bisphosphonates, such as >> << is used to treat and prevent osteoporosis, should further clarify how long patients can take them, FDA Advisory Group voted today. But the panel retreated to give any specific dates. Bisphosphonates include Aclasta, Actonel, Altevia, Боніва, Fosamax, and. Four million to five million Americans fill

drug each year, according to FDA

FDA convened a meeting because of emerging safety problems associated with long-term use - usually considered to be more than 4:57 years - bisphosphonates. In particular, the agency received reports of osteonecrosis or bone death and jaw >> << unusual femur or thigh bone, in women who took drugs for several years or more. Meanwhile, some studies show that as bisphosphonates remain in bones for many years, women can still benefit after they stop taking them. Additional information about the label panel, consisting of the Advisory Committee on Drugs Reproductive health and safety of medicines and Risk Management Advisory Committee voted 17 to 6 in favor to recommend additional information on the labeling of drugs long-term safety and efficacy. FDA usually, but not always follow the recommendations of its advisory committee. Own analysis of the agency concluded that women who continue to bisphosphonates therapy after five years of operation there are obvious benefits or harm and no evidence of a subgroup of patients who have "a clear and consistent" to reduce the risk of fractures, FDA scientist Teresa Keho , MD, told the panel. Bisphosphonates labels indicate that the effectiveness and safety information on the basis of one to four years - depending on the drugs - these clinical trials Keho said, but the optimal length of use is unknown. "It's really a problem that is in the center of the room and primary care," said Douglas Bauer, MD, University of California, San Francisco, the main doctor asked the FDA for the Consultative Group. Although not ideal to study the long-term use, the only published study to make it part Fosamax, said Bauer. This study randomized women who like to take Fosamax daily for five years in clinical trials or to continue receiving the drug for another five years or to stop. For fractures other than those of the spine, there is no evidence of overall benefit continuation within five years, said Bauer. But it was 55% lower risk of spine fractures in women who continued taking Fosamax for an additional five years, said Arthur Santoro, executive director of clinical research for the

and Endocrinology Drug Merck, which makes the drug. In the study to 10 years of use, Santoro said there were no reports of death of the jaw and no difference in risk of hip fractures unusual women who took drugs and those who did not. Long-term use of Bisphosphonates Experts said it is difficult to predict which women will benefit from long-term use of bisphosphonates lasix 240 mg. Fosamax study found that women bone mineral density at the time they stopped the drug closely related to their risk of fracture over the next five years, Bauer told the group. The data probably can be summarized in a weekly dosage Fosamax, he said, but it is unclear how they relate to other bisphosphonates. Paul Miller, MD, Medical Director of the Colorado Bone Research, noted that long-term use was not a problem when bisphosphonates first appeared on the market. While "we do not consider many women in the 50's or early 60's bisphosphonates," said Miller, who represented Warner Chilcott, producer Actonel. "We treated worse than women in the 70's and 80's."

In July 2002 the first published results of the initiative in the name of women's health, everything changed, he said. The study showed that most sold brand in postmenopausal estrogen increased stroke risk and the

. In postmenopausal women who were on hormone therapy to protect their bones flooded doctors' offices in search of alternatives, said Miller. Most patients bisphosphonates who testified before the commission on his unusual hip fractures said that they started using drugs in the 50's or 60's. Some women said they were offered drugs, which means that their bone mineral density was lower than usual, but not enough to be classified as osteoporosis. Advisory committee member Clifford Rosen, MD, director of clinical and translational research in the Medical Center of Maine Research Institute in Scarborough, questioned the feasibility of bisphosphonates appointment just for prevention of osteoporosis, rather than treating it. "Prevention of an indication, I think, now again the opposite, including the FDA," said Keho response. "Of course, this is what we are fighting corruption and decisions."

It&#39;s a good idea to train with a partner ...

Credit Photos fitness weight image, William Berry of Fotolia. com

Osteoporosis is a condition that weakens the bone so that they break easily - especially bones of the hip, spine and wrist. It is most common among postmenopausal women, but can affect others. Because bone can adapt to the stresses placed on them by performing resistance exercises can help increase bone density and thus reduce the likelihood of fractures. National Osteoporosis Foundation recommend 30 minutes of full body resistance exercise a day for two or three days a week for prevention and treatment of osteoporosis. Exercises can be performed using dumbbells, free weights, weight machines and / or resistance bands for a set of eight to 15 repetitions. Crunch is an effective abdominal exercises. Lie on your back, knees bent, feet on the floor. Lift your shoulders six inches from the floor and then slowly lower down. To use your hands, try bicep curls, triceps extensions and wrist curls and extensions. For biceps curls and triceps extensions standing start. For curls, keep your weight in each hand to hip hands away from the body. Bend your elbows to move the weight on your shoulders. When your hands are completely bent so that the palm faces your shoulder, reverse movement. For triceps extensions, keeping weight in both hands behind your ear elbows pointed up and palms together lasix drug reactions. Perform the exercise by extending the hand so that the weight to move the head. When the hand is fully extended, slowly lower the weight back to starting position. For wrist curls and extensions, especially bending forward from a seated position, your elbows and forearms rest on the hip and wrist and hand hanging over knees. Keep weight on both hands and fully bend and extend the wrists of both hands on exercises. Start with your hands up and down scrolls and expansion. Lat pulldowns and pull straight legs are back. Lat pulldowns performed on a machine specifically designed for exercise. Put your hands on top of the far wider than shoulder width apart. Using only the arms and back muscles, pull the bar straight to the chin and then slowly extend the hand, allowing the bar to get back up. Run a straight thrust with his feet standing position. Begin in the same position, biceps curls, but keep the weight on your palms of your body. Bend your torso forward to reduce the weight of the hand aligned with your ankles. Then extend the hips and torso, while you stand back. Keep your knees slightly bent and back flat throughout the movement. Regimes of the chest and shoulders and triceps to a degree. Lie face up on the bench, put your feet on the ground. Hold the weight in your hands close to the shoulders, arms bent, elbows pointed down and palms on your head. Perform the exercise by extending your hand to press the weight straight up. Then slowly lower back to starting position. For legs, try squats and five raises. Squat to the top of the toe and heel raises are calf muscles leg. For both exercises, standing on your feet shoulder width apart and hold a weighted barbell from behind neck, the upper back and shoulders with both hands. For squats, lower thighs and bend your knees until thighs are parallel to the ground and then reverse the movement until you are standing again. Keep your head and spine straight all training. For the heel raises, as the name suggests, raise your heels from the floor as high as possible and then slowly release them back to earth. It's a good idea to train with a partner, so that it can help you if you have problems with balance and / or lifting weight for any exercise, especially if you are using dumbbells or free weights. "Exercise Physiology: Energy, Nutrition and Human Performance (Fifth Edition)", William D. MakArdl, Frank I. Kacha Kacha and Victor L., 2001

article JA Growth Update: August 11, 2011.

Because of this body is producing so much estrogen.

What is osteoporosis? Osteoporosis is a disease affects the bones of the body. If someone has osteoporosis their bones become fragile due to loss of bone density and is easier to break. This type of problem often occurs in older women and is common in patients with eating disorders, anorexia. Many people who suffer from anorexia seek treatment in clinics are treating the disorder. Lack of calcium in the body, often the main cause of osteoporosis. Possible risks do increase the development of this issue include: >> << What is anorexia? Anorexia nervosa is a popular type of eating disorder. This can occur in men and women, but is most common in women. Those with this disease is a very small amount of food or completely give up eating nothing. Anorexia decided not to eat because their bodies are perceived distortion. This distortion is caused by factors such as past traumatic experiences, stress, and sudden changes in life. Signs of anorexia include:

Hair loss, thin hair

Exhausted, sleepy >> << If anorexia continues for a prolonged period, amenorrhea (loss of menstrual cycle), in the end there. Death can lead to serious cases of this disease. If you or a loved one struggling with anorexia, it is important to look for anorexia treatment. This eating disorder treatment can be found in one of the many different centers treating anorexia nervosa. Anorexia is a serious eating disorders, which, if continued, may cause serious damage to human body. One form of this complication is the damage it may cause osteoporosis. Osteoporosis is a result of a number of changes in the body. First, nutrition levels are low in the body as a result of lack of appetite for food. Because of this body is producing so much estrogen. Lack of estrogen in the body, it causes menstrual cycles cease, a condition known as amenorrhea. This last factor that causes poor bone density in the body. Other factors that may contribute to osteoporosis include calcium deficiency, weight loss, reduced growth hormone in the body, and lack of sufficient testosterone (in men). In addition, the excess level of adrenal hormone cortisol, a hormone that promotes bone loss is usually very common in people with anorexia. Anorexia can be very harmful eating disorders. For those who want to overcome this disorder, anorexia treatment eating disorders residential center is often useful. Like others living in your body, bones need care, or they will weaken. If a person does not consume enough calcium-rich foods, bones in the body is not very strong. In addition, a person lacks vitamin D in their diet, they can not absorb calcium. Due to the fact that most of anorexia have little, if any, fat in their diet, vitamin D can not be taken in. If someone continues the cycle of anorexia, over time they will eventually develop osteoporosis or osteopenia, a disease where a person has low bone mass. Many young women who develop anorexia, poor development of bones developed, so osteoporosis is often the case. If you or a loved one struggling with anorexia, call center is the treatment of disorders today. I am looking for treatment at an early stage is the first step in preventing serious consequences of osteoporosis. Osteoporosis caused by anorexia can be very harmful to the body, especially if it will go without treatment.

The following steps can help those who want to prevent osteoporosis or manage existing osteoporosis. Do not use excessive amounts of alcohol. Maintaining a healthy diet. Vitamin D and calcium are two main vitamins that are crucial for bone health of your body. If you do not get enough of these vitamins in your diet, supplements may be helpful. Consider hormone replacement therapy. Constantly train. Exercise makes bones in the body stronger. If your body is very weak, you may need to talk to an experienced professional when considering which forms of exercise are safe for you. Weight bearing exercises are most effective. There is a bone density test. This test will tell you the current density of the bones and determine how much you have suffered from osteoporosis. Avoid smoking. Take prescribed medications. Taking medication prescribed by your doctor can help, especially if you're older and have eating disorders, anorexia. Today, however there is still no cure for osteoporosis. Keeping the monthly menstrual cycle. Anorexia is a serious disorder. In lasix heart medication fact it is so serious that anorexia treatment is often necessary for recovery. This type of treatment eating disorders can be found on anorexia treatment centers in different regions. If the treatment is started early, there is less chance of developing osteoporosis. Call a treatment of anorexia today and finally open the recovery and healing. [