Office of the Chief Rabbi


By F. Nafalem. University of Iowa.

The spleen is responsive to blood born antigens Spleen and the lymph nodes protect the body from The spleen (Fig discount zenegra 100mg on-line. Beneath the collagenous capsule is the subcapsular sinus zenegra 100mg sale, which is lined with phagocytic cells. Lymphocytes and antigens from surrounding tissue spaces or adjacent nodes, pass into the sinus via the afferent lymphatics. The cortex contains aggregates of B cells (primary follicles) most of which are stimulated (secondary follicles) and have a site of active proliferation or germinal center. The paracortex contains mainly T cells, many of which are associated with the interdigitating cells (antigen-presenting cells). The medulla contains both T and B cells, as well as most of the lymph node plasma cells organized into cords of lymphoid tissue. The ginal zones and a small amount of associ- branches of the splenic artery (trabecular ated connective tissue are together called artery) travel along the trabeculae and on white pulp. Each arteriole is encased in rounding the central arteriole is thymus de- a cylindrical cuff of lymphoid tissue that pendent area of the spleen. These Blood flows from the arterioles into the are identical to the follicles found in other red pulp, a spongy blood filled network of re- lymphoid tissues and are composed mainly ticular cells and macrophage lined vascular of B cells surrounding the sheath and lym- sinusoids that makes of the bulk, of the spleen phatic follicles. Then the spleen serves respiratory system, to detect any foreign as a critical line of defense against blood- substances that contact these body surfaces. Spleen, besides acting as a In most areas, the cells form diffuse disor- blood filter, also serves eliminating abnormal ganized mass with occasional isolated lym- damaged and senescent red or white cells phoid follicle. At other site, the cells are organized into Tonsils, Peyer’s Patches and other discrete stable anatomic structures such as Subepithelial Lymphoid Organs tonsils, Peyer’s patches. Tonsils are nodular Dense population of T and B lymphocytes, aggregates of macrophages and lymphoid plasma cells macrophages can normally be cells, without a capsule, lies beneath the Fig. Blood enters the tissues via the trabecu- lar arteries, which give rise to the many-branched central arteries. Some end in the white pulp, supplying the germinal centers and mantle zones, but most empty into or near the marginal zones.

Twenty-one patients benefited from readjustment of the sling during the follow-up 100 mg zenegra for sale. The tension was increased in 17 cases (continent at discharge) due to recurrence of stress incontinence cheap zenegra 100mg free shipping, and reduced in 4 due to obstruction. More recently, long-term results after 5 years were presented in a cohort of 30 patients, most of them with severe intrinsic sphincter deficiency and fixed urethra. In this series, according to objective evaluation (pad text and cough stress test), 93% were considered cured/improved. Readjustments can be done under local 1184 anesthesia at immediate or delayed follow-up as needed. However, the evolution of transobturator prosthesis and the emerge of minislings have moved adjustable slings for restrict subset of patients. As the devices presented are used in specific situations nowadays, the reports are rarely published. So, more studies are needed for both techniques to corroborate the existing data in a sense to provide longer follow-up and more precise success criteria assessments. An integral theory and its method for the diagnosis and management of female urinary incontinence. Safyre sling: Early results of a new tension-adjustable and self-anchoring device for female stress incontinence. Sling Transobturatório Reajustavel: Uma abordagem promissora na Incontinência Urinaria de esforço. Transobturator tape (Uratape): A new minimally-invasive procedure to treat female urinary incontinence. Comparative results of two techniques to treat stress urinary incontinence: Synthetic transobturator and aponeurotic slings. Transobturator crossover readjustable sling for severe female incontinence: Technique and preliminary results. Spiral sling salvage anti-incontinence surgery in female patients with a nonfunctional urethra: Technique and initial results. Surgical treatment of stress urinary incontinence using a method for postoperative adjustment of sling tension (Remeex System).

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Accurate history and clinical examination and investigations are essential in identifying a cause for each patient’s symptoms zenegra 100mg free shipping. The primary function of the colon is the absorption of water from the small bowel effluent cheap zenegra 100 mg online, leaving 100–150 mL of water in feces. A secondary function is to enable bacteria to ferment undigested fiber; the rectum stores feces until defecation takes place. The colon, rectum, and internal anal sphincter (continuation of the smooth muscle) are extrinsically innervated by the autonomic nervous system. The sympathetic innervation via the coeliac, superior, and inferior mesenteric plexus and hypogastric nerves (T11–L2) inhibits peristalsis and are sensitive to distension. The parasympathetic innervation by preganglionic vagal fibers and S2–4 splanchnic nerves increases peristalsis, contracts rectum, and relaxes internal anal sphincter to assist defecation. The intrinsic enteric nervous system (submucosal and myenteric plexuses) influences contractions and tone while the cells of Cajal are pacemakers. In order to be considered of medical significance, symptoms must be present for at least 3 months with onset of symptoms 6 months before diagnosis [5]. Subtypes of Constipation Constipation can be divided into the following subtypes: 1. Motility disorder: Decreased high-amplitude peristaltic contraction causing slow transit constipation. Patients with severe colonic inertia may have a more diffuse motility disorder [6]. An accurate history from the patient is important and should include size, consistency, and frequency of defecation and duration of symptoms. The presence of mucus or blood in or on stool and history of abdominal or perianal pain should be ascertained as well as any difficulty in evacuation, need for perineal pressure, or digitation vaginally or rectally. Patients with slow transit constipation may complain of infrequent bowel movements and lack of urge to defecate despite laxatives. Patients may have additional symptoms of urinary dysfunction or symptoms of uterine or vaginal prolapse, implying more global pelvic floor abnormality and dysfunction. A thorough obstetric history may reveal a history of obstetric trauma; high vaginal parity; prolonged labor, which may be associated with uterine prolapse; enteroceles; rectocele; and descending perineal syndrome.

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Primary Conditions Vesicovaginal Fistula The level of impaction during labor determines the site of injury buy zenegra 100mg on-line. If the impaction occurs at the pelvic inlet buy 100 mg zenegra fast delivery, the vesicovaginal fistula may be juxta- or even intracervical [22] (Figures 109. The urethra is injured in 28% of cases with 5% of patients in Ethiopia having the urethra completely destroyed [21]. This has prognostic indications as the mechanisms for continence in the female have been destroyed [17,23,24]. Ureteric Injury In a small number of obstetric fistula cases, the lower part of the ureter can be involved. The whole ureterovesical junction is necrosed and sloughed away, leaving the vesicovaginal fistula with the ureter draining outside of the bladder straight into the vagina. It is becoming more common to see isolated ureterovaginal fistulae after cesarean section or cesarean hysterectomy, more commonly on the left, and these are iatrogenic, occurring at the time of operative delivery [2,25]. Rectovaginal Injuries A rectovaginal fistula occurs if the presenting part is impacted against the sacrum during labor, causing ischemic necrosis of the rectovaginal septum. It has various reported prevalence and seems to vary geographically, ranging between 6% (B. If present, it usually occurs in conjunction with a vesicovaginal fistula, rarely presenting in isolation [4]. The status of the anal sphincter should always be noted as there may be residual flatal or fecal incontinence even after repair [26]. Reproductive Tract The tissues of the vagina are obviously injured, but in some cases, the whole vagina has necrosed, leaving little or no identifiable remaining vaginal epithelium (Figure 109. The cervix is often torn or partly necrosed and fistula surgeons testify that it is rarely that one will see an uninjured cervix. Muscles The muscles of the pelvic basin are often affected by a neuropathy, directly weakened by the ischemic process or even completely destroyed. A recent ultrasound study of the levator muscle complex in obstetric fistula patients showed little muscle loss and little denervation [27], but certainly in extensive injuries, an “empty pelvis” is all that remains. Bones A series by Cockshott performed x-rays on 312 women with obstetric fistula and found that 32% had some x-ray abnormality, ranging from bony resorption, bony spurs, obliteration or separation of the symphysis pubis [28].