Why should we invest in safe health facilities in emergencies?
WHO’s Eastern Mediterranean Region is home to some of today’s most intractable crises. Natural disasters, conflicts and other emergencies continue to affect populations across the region, putting the health services under extensive strain.
Ladies and Gentlemen
We are all still living the tragedy of Gaza and the catastrophe resulting from the destruction of the health facilities there. This is a violation of international law and should be considered a war crime and a grave crime against health. We also still remember the earthquake that hit Pakistan in October 2005. In a few seconds, out of 796 health facilities ranging from sophisticated hospitals to rural clinics, 388 were completely destroyed. The remaining facilities that were able to continue functioning were utterly overwhelmed. The health care workforce was also severely affected by this event.
In the past five years, over 800 health facilities were partially or fully damaged from several events within the region. They were earthquakes in the Islamic Republic of Iran and Pakistan, conflict in Iraq, Lebanon and Palestine, a cyclone in Oman and floods in Yemen. Natural disasters and all sort of emergencies can affect anyone, anywhere.
Although climate change and the subsequent warming of the planet may be gradual, the increasing frequency and severity of extreme weather events—intense storms, heat waves, drought and floods—will be abrupt and the health consequences will be acutely felt.
Health facilities are about more than just bricks and mortar. In addition to their physical structure, health facilities must have the functionality to continue providing services throughout and after the events in order to save lives. Functional collapse, not structural damage, is the usual reason for hospitals being put out of service during disasters.
A crisis happens when it is least expected, and we know that disasters can hit at any time. Saving lives can only be achieved if proper investments are made in emergency preparedness and training of the health workforce. Hospital failure and health system disruption during emergencies is as often due to system overload and lack of contingency planning as of physical failure. Staff training is just as important as physical protection.
Incorporating comprehensive disaster protection for earthquakes and extreme weather events into new building designs adds only an additional 4% to total costs. We must remember that when a hospital is out of service, many thousands of people are left without health care. In the long run, disruption of essential health services affects a country’s development potential.
Don’t let health facilities be another victim of emergencies.
Thank you.

MORPHOLOGICAL FEATURES

Gross
neuroblastomas are usually large,soft,grey and relatively well circumscribed;areas of hemorrhage,necrosisand calcification are often present.some time hemorrhage is so extensive as to mimic hematoma.cystic degeneration also occur.
Microscopy
The pattern of growth is vaguely nodular as a result of delicate,incomplete fibrous septa.the tumor cells are small and regular,slightly larger than small lymphocyte.Homer-wright’s rosettes are present,characterized by collection of tumor cells around a central area filled with a fibrillary material,which is mass of nuerites as revealed by silver stains.

ELECTRON MICROSCOPY
Ultra structurally , neuroblastoma cells are characterized by the presence of neuritis ,neurosecretory granules and synaptic endings the neuritis form a complex interdigitating meshwork in the centre of rosette
Immunohistochemistry
Neuroblastoma cells expresses neuron-specific enolase, neurofilaments, neurofilament-66/a-internexin, peripherin, chromogranin, synaptophysin, secretogranin 2, vasoactive intestinal peptide, microtubule associated proteins, NB 84, nerve growth factor receptors and other neuron related antigens including cell surface ganglioside GD2. Expressoin of Insulin- like growth factor 2 is associated with a lobular growth pattern and good cytological differentiation.
Neuroblastoma produce catecholamines which can be demonstrated in sections or touch preparations by the twchnique of formaldehyde- induced fluorescence.
Chromosomal and molecular markers
During last 2 decade, many chromosomal and molecular abnormalities have been identified in neuroblastoma. these biologic markers have been evaluated to determine their value in assigning prognosis,and some of these have been incorporated in to the stratergie sused for risk assignment
The most important of these biologic markers is MYCN ,which is over expressed oncogene in neuroblastoma with amplification of distal arm of chromosome 2.it is amplified in approximately 25% of do novo cases and is more common in patients with advanced-stage disease,and is marker of poor prognosis.in contrast to MYCN ,H-ras oncogene correlates with lower stage of the disease.
Deletion of short arm of chromosome 1 is most common chromosomal abnormality, which confers poor prognosis. Other alleic losses of chromosomes 11q, 14q, 17q and gain of chromosome 1 have been reported.
DNA index is another useful test that correlates with response to therapy in infants. Look.et al demonstrated that

Lab studies
• General laboratory studies should be routinely obtained in children suspected of having neuroblastoma.
•
o A CBC count should be obtained to determine if the child has anemia, which typically does not occur until the tumor has become widely disseminated.
o Once dissemination occurs, abnormalities in findings of coagulation studies (prothrombin time [PT], activated partial thromboplastin time [aPTT]) may secondary to liver involvement. Thrombocytopenia due to overwhelming bone marrow involvement may also be present.
o The erythrocyte sedimentation rate, a nonspecific acute-phase reactant, is elevated in classic neuroblastoma.
• Specific laboratory studies should be obtained when the diagnosis of neuroblastoma is considered.
•
o Metabolic tumor by-products are useful as diagnostic inclusion criteria for detecting neuroblastoma.
o Elevated metabolic catecholamine by-products can be detected in the urine of patients with neuroblastoma.
o Phenylalanine and tyrosine are catecholamine precursors, which are converted through a sequence of enzymatic events to dihydroxyphenylalanine (DOPA), dopamine, norepinephrine, and epinephrine.
o DOPA and dopamine are metabolized into their final product, homovanillic acid (HVA), while norepinephrine and epinephrine are metabolized into vanillylmandelic acid (VMA).
o Ninety percent of neuroblastoma tumors secrete these by-products. This fact becomes clinically relevant because children with dedifferentiated tumors excrete higher levels of HVA than VMA. This occurs because dedifferentiated tumors have lost the final enzymatic pathway that converts HVA to VMA. A low VMA-to-HVA ratio is consistent with a poorly differentiated tumor and indicative of a poor prognosis.
o Neuroblastoma cells lack the enzyme that converts norepinephrine to epinephrine. Despite this fact, elevated levels of norepinephrine are not identified in the serum of patients with neuroblastoma. This might be explained by at least 2 processes—(1) norepinephrine may be catabolized within the tumor; or (2) tyrosine hydrolase, the initial enzyme in catecholamine synthesis, is subject to a negative feedback loop by norepinephrine. For either or both reasons, norepinephrine does not reach detectable serum levels.
o A LaBrosse VMA spot test may be used to screen patients in certain institutions. It is economical but has low sensitivity and specificity.
o High-performance liquid chromatography has a much lower false-positive rate and is more sensitive than the LaBrosse VMA spot test, but its only drawback is that it is more expensive and is therefore often used only to confirm a positive result on spot test.
• Nonspecific tumor markers can be identified in patients with neuroblastoma.
•
o Neuron-specific enolase (NSE), lactic dehydrogenase (LDH), and ferritin are markers useful in the identification of active disease, as well as in prognostication.
o Approximately 96% of patients with metastatic neuroblastomas demonstrate an elevated NSE level, which has been associated with a poor prognosis.

Imaging studies
Radiographic assessment is recommended in all infants and children with an abdominal mass. The standard diagnostic imaging modalities include plain abdominal radiography (kidneys, ureters, bladder [KUB]), renal/bladder ultrasonography, bone scintigraphy, and CT scanning or MRI.
• KUB most commonly reveals finely stippled calcifications of the abdomen or posterior mediastinum.
• Renal/bladder ultrasonography improves the diagnostic evaluation and is probably the single best imaging modality to obtain. Ultrasonography is noninvasive and provides relevant information regarding the laterality, consistency, and size of the mass.
• Abdominal CT scanning or MRI usually follows ultrasonography. Both of these studies are more invasive, in that they require general sedation for young children. The benefit is that they enhance the ultrasonographic findings by providing information about regional lymph nodes, vessel invasion, and distant metastatic disease.
• Bone scintigraphy and a skeletal survey to detect cortical bone disease are helpful in the diagnosis of neuroblastoma. Metaiodobenzylguanidine (MIBG) is a compound taken up by catecholaminergic cells that competes for uptake even in neuroblastoma cells. In this way, MIBG is quite sensitive and specific in the detection of metastasis to bones and soft tissue, with highest sensitivity (91-97%) in the detection of bone deposits. Bone scintigraphy using 99Tc diphosphonate and a skeletal bone survey to detect cortical bone disease are essential if MIBG scintigraphy results are negative in the bone. MIBG is recommended for re-assessment both during and after therapy in high-risk patients with MIBG-avid disease at diagnosis.
• Expression of somatostatin (SS) receptors has been described in neuroblastoma cell lines and tumors. Studies have shown that these tumors can be successfully targeted with radioactive SS analogs as a method of detection. Currently, the indication for radio-labeled SS analog in children with neuroblastoma is not well-defined because this method is less sensitive than MIBG scan (64% vs 94%). However, because neuroblastoma SS receptors are associated with favorable clinical and biological prognostic factors, radio-labeled SS analog could provide valuable information. In fact, improved survival has been found in patients with SS receptor–positive neuroblastoma. However, more studies need to be performed to confirm the benefits of SS receptor scanning.

The international neuroblastoma staging system (INSS)

Stage 1 Localized tumour with complete gross excision, with or without microscopic residual disease; representative
ipsilateral lymph nodes negative for tumour microscopically (nodes attached to and removed with the primary
tumour may be positive).
Stage 2A Localized tumour with incomplete gross excision; representative ipsilateral nonadherent lymph nodes negative for tumour microscopically.
Stage 2B Localized tumour with or without complete gross excision, with ipsilateral nonadherent lymph nodes positive for tumour. Enlarged contralateral lymph nodes must be negative microscopically.
Stage 3 Unresectable unilateral tumour infiltrating across the midline (vertebral column) with or without regional lymph node involvement; or localized unilateral tumour with contralateral regional lymph node involvement; or midline tumour with bilateral extension by infiltration (unresectable) or by lymph node involvement.
Stage 4 Any primary tumour with dissemination to distant lymph nodes, bone, bone marrow, liver, skin and/or other organs (except as defined for stage 4S).
Stage 4S Localized primary tumour (as defined for stage 1, 2A or 2B), with dissemination limited to skin, liver and/or bone marrow (limited to infants <1 year of age).

History

Neuroblastoma was first described by Sir Rudolf Virchow in 1864 and at that time it was

referred as glioma.

In 1891 Marchand histologically linked Neuroblastoma to sympathetic ganglia.

Herxheimer,In1914 gave the substantial evidence of neural origin by demonstrating the fibrils of the tumor stained positively with special neural silver stains.

In 1927, Cushing and WOlbach first described the transformation of malignant Neuroblatoma

into its benign counterpart , ganglioneuroma.IN 1957, Mason published report of a child with

Neuroblastoma whose urine contained pressor amines which helped to understand the possible

origin from sympathetic neurons.

causes:

The etiology of Neuroblastoma is not well understood.

Several risk factors have been prposed and are the subject of ongoing research.

Due to characteristic early onset , many studies have focused on parenteral factors

around conception and during gestation.Factors investgated have included

occupation , that is exposure to chemicals in specific industries,smoking,

alcohol consumption, use of medicinal drugs during pregnancy.

However results have been inconsistent.

Neuroblastoma can exhibit familial incidence .

It can be associated with Beckwith-wiedemann syndrome,

HIrschprungs, Neurofibromatoses or occur as a complication of fetal hydantoin syndrome.

Neuroblastoma has been called the great mimicker because of its myriad clinical

presentations related to the site of tumor, metastatic disease and its metabolic tumor

byproduct.The most common site of neuroblastoma is abdomen arising either in the

adrenals or less commonly in the para midline sympathetic chains.

Other sites being neck, mediastinum, pelvis.Neuroblastoma is one of the rare human

malignancies known to demonstrate spontaneous regression from undifferentiated to

a completely benign cellular appearance.

The initial symptoms are often vague and often include fatigue,

loss of appetite and fever.Later symptoms depend on tumor location.

The most common finding on physical examination is a non tender ,

firm,irregular abdominal mass.at the time of diagnosis ,the site of neuroblastoma

predictably age dependant.Infants often present with compression of sympathetic

ganglia in thoracic region which might result in Horner’s syndrome

(mioses, anhydrosis and ptosis)or Superior vena cava syndrome.

Older children typically present with abdominal complaints.

More than 50% of patients presenting with neuroblastoma have metastatic disease,

which resulted in syndromes. Pepper Syndrome occurs in infants with

metastatic deposits in liver. it generally confers a better prognosis, however,

may die of massive hepatomegaly,respiratory failure and overwhelming sepsis.

ROUX en Gastric Bypass

Considered the gold standard in bariatric surgery, a Roux-en-Y gastric bypass is what is known as a combined restrictive and malabsorptive procedure. It is restrictive because the stomach is reduced to a small pouch that can only hold a very small amount of food at a time. It is malabsorptive because a portion of the small intestine is bypassed, reducing the body’s ability to absorb the full amount of calories that are consumed. These two factors, working together, make this procedure extremely effective at helping patients shed large amounts of excess weight. We perform laparoscopic gastric bypass at our practice serving Fort Worth, Arlington, and the entire Dallas region so that patients can enjoy the benefits of bariatric procedures without the discomfort of open surgery.

• Laparoscopic Roux-en-Y Gastric Bypass
• Benefits
• Risks

Laparoscopic Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass involves the separation of the stomach into two sections. The small upper portion can collect and digest food, but only in very small quantities. This small stomach pouch is then connected to the middle portion of the small intestine. The remainder of the stomach and upper segment of the small intestine are left in place, but bypassed. These bypassed segments are responsible for producing certain necessary digestive acids and proteins, which they will continue to do, even though food will no longer pass through them.

Traditionally, Roux-en-Y has been performed as an open procedure, involving a significant amount of pain, a long recovery time, and substantial surgical risk. Using laparoscopic techniques, we can perform the same gastric bypass procedure at our Dallas, Arlington, and Fort Worth-area practice while using only five small incisions. This results in a much shorter and easier recovery and virtually no noticeable scarring.

Benefits

There are many reasons why this procedure has become the leader in the field of bariatrics. First and foremost, it is extremely effective for the majority of patients. It does not involve the use of any implanted device, like gastric banding, and because nothing is removed, it is technically reversible, although this is strongly advised against.

People who have undergone gastric bypass surgery have experienced reduction or resolution of such conditions as type 2 diabetes and acid reflux disease, even before a significant amount of weight is lost. As the weight comes off, additional benefits include decreased hypertension, increased energy, reduced pressure on the joints, and improved confidence.

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Risks

Gastric bypass surgery, like all surgery, carries an inherent amount of risk. Although patients who are obese present with a more complicated medical history, bariatric surgery is actually statistically safer than many of the common surgical procedures performed every day in the United States. At Minimally Invasive Bariatrics, we thoroughly discuss all of the potential risks with each patient prior to surgery.

After the surgery is complete, some side effects associated with Roux-en-Y gastric bypass could still occur. Due to the malabsorptive aspect of the procedure, some patients experience vitamin or nutrient deficiencies. This can be avoided by carefully following the dietary guidelines provided by our practice and taking the recommended vitamin supplements. Many patients have also experienced an extremely uncomfortable side effect known as “dumping syndrome,” which is caused by the stomach emptying food into the intestine too quickly. This is most often triggered by the consumption of high-fat or sugary foods, so once again, following a proper Post-bariatric diet will minimize the chances of this condition appearing.

Minimally Invasive Bariatrics is committed to providing our patients with the best care possible. As part of this commitment, we offer a wide range of procedures, which we perform using only the most advanced minimally invasive methods available.

Often called the gold standard in bariatric surgery techniques, Roux-en-Y gastric bypass is a well-established weight loss surgery procedure that involves permanently altering the path of the upper digestive system. Learn more about Roux-en-Y surgery.

The LAP-BAND® System is a popular alternative to the classic gastric bypass surgery, as it restricts the amount of food that can be consumed without making permanent structural changes to the digestive system. Find out how the LAP-BAND® System and other gastric banding options, such as the REALIZE™ Band, work.

The sleeve gastrectomy is a relatively new form of bariatric surgery offered at Minimally Invasive Bariatrics in Arlington, Dallas, and the Fort Worth area. It involves reducing the size of the stomach as well as the stomach's ability to produce certain appetite-inducing hormones. Read more about sleeve gastrectomy.

StomaphyX™ allows surgeons to access the stomach through the esophagus, eliminating the need for incisions altogether. This results in significantly shorter healing times and no visible scars whatsoever. Learn more about StomaphyX™ and whether this remarkable technology might be right for you.