Living donor liver transplantation has become a widely accepted alternative to cadaveric transplantation (1,2). Such living donor grafts provide similar or better short-term graft function and long-term survival rates when compared with cadaveric liver grafts, especially in children (3,4). This procedure has the advantages to shorten waiting list time and to minimize cold ischemia time. However, the surgical risk brought upon donors remains the most important concern (4,5). In the setting of adult to adult liver transplantation, the development of major liver resection has been slow, due to an increased technical complexity and significant donor morbidity (near 40%) (6,7).
The rising of laparoscopic liver resections, initially for tumors, has been limited in live donor hepatectomy (LDH), due to initial uncertainty on its technical feasibility and safety, especially for major hepatectomy. Lately, this approach has gained more acceptance, demonstrating significant advantages such as decreased postoperative morbidity (8-11) shorter hospital stay (11,12), and reduced global costs (13). Hence, laparoscopic approach is now considered as the standard technique for several procedures, such as left lateral sectionectomy (14,15).
In the meantime, laparoscopic living donor nephrectomy has become the standard approach for renal transplantation, exhibiting reduced morbidity and faster recovery, which led to increased donation rates (16). The application to liver donation for transplantation may bring the same benefits and help to minimize surgical trauma from the large abdominal incision. In this setting, laparoscopic left lateral sectionectomy for living donation has gained wide approval and is now considered as the standard technique in expert teams (17,18). The development of laparoscopic live donor major hepatectomy, despite slower, seems promising, due to accumulating experience and constant refinements.
The objective of this article is to review and discuss every aspect of laparoscopic live donor right hepatectomy, from surgical indication to technical aspects.
The development of laparoscopic right hepatectomy for living donation: initial experience, evolution and current position
Initial experience of live donor right hepatectomy
The first LDH for a pediatric transplantation was reported in 1989 and 1990 (1,2). Since then, LDH has developed mostly in Eastern countries, owing to deceased donor scarcity. The first case of a right liver donation for adult liver transplant was then described in 1994 by Yamaoka et al. (19).
In the very first developmental stage, LDLT was considered with great enthusiasm, and accounted for 10% of the total amount of the United States liver transplantations in 2001 (20). Further reports of an approximate 0.2% mortality (4) and 40% complication rate (7,21) associated to open right LDH were published. Reported complications included biliary leak, sepsis or pulmonary complications (22,23). These risks, associated with reported psychological difficulties (7) may have dissuaded donors and troubled general opinion, as well as medical teams. While LT from available deceased donors remains an alternative in Western countries, these potential risks led to some reticence among medical teams and to a significant decrease in the number of procedures, which now account for 4% of the total liver transplantations in the United States (20).
In this context, several expert teams recommended the laparoscopic approach for LDH as a way to reduce donor morbidity.
The first cases of laparoscopic LDH have been reported by in 2002 (24). Full laparoscopic left (25,26) and right (27-29) hepatectomy were reported for adult-to-adult transplant afterwards. Besides the pure “full” or “totally” laparoscopic approach, the hand assisted laparoscopic technique and the laparoscopic assisted or “hybrid” technique (30,31) were described. There is currently no evidence in the literature demonstrating the superiority of one technique over the others (32).
Evolution and learning curve of laparoscopic right LDH
The diffusion of the laparoscopic approach for right LDH was slower than the open technique, owing to several concerns: (I) the overall technically demanding technique; (II) concerns regarding donor safety, especially with the risk of hemorrhage during surgery; (III) concerns regarding the graft safety and prolonged warm ischemia time due to its extraction; and (IV) the lack of comparative studies with the standard open approach.
Indeed, laparoscopic major liver resection for LDLT requires expertise in both LDLT and laparoscopic liver surgery. Several reports demonstrated that a learning curve of minimum 15–60 procedures was necessary to reach optimal results (33,34). Moreover, the small proportion of major hepatectomy for LDLT performed annually, especially in Western countries (35), contributes to the slow progression of the technique.
However, there is now accumulating evidence that laparoscopic right hepatectomy for classical liver resection demonstrates better surgical outcomes than the open approach, with reduced postoperative morbidity (8,10,11), shorter hospital stay (11,12), or improved cost effectiveness (13).
The technical improvements and growing expertise of the last two decades in laparoscopic liver resection allowed reducing blood loss and transfusion rates compared to patients undergoing open liver resection (36,37). For example, more effective hemostasis devices, magnified laparoscopic vision with 30° laparoscopes, reverse Trendelenburg positioning in order to reduce hepatic backflow, or pneumoperitoneum increase (38,39) have been described to improve intraoperative bleeding management. Moreover, the surgical community benefits from accumulating experience on laparoscopic left lateral sectionectomy for living donation, which had gained broad acceptance through standardization of the technique and excellent reported outcomes (17,18).
In the setting of fully laparoscopic LDH, several authors have raised some concerns for graft integrity during its extraction in a plastic bag through a small incision and the possible associated prolonged warm ischemia time (40). Our team demonstrated that even though laparoscopy-retrieved grafts undergo increased warm ischemia time, this had no impact on graft-related complications or survival (41).
Since a randomized controlled trial is very unlikely in this setting, accumulating evidence on the benefits of laparoscopic approach in LDLT rely mostly on retrospective or case-matched reports, but definitely contribute to the global acceptance and development of the technique. To date, 167 cases of laparoscopic right hepatectomy for adult-to-adult LDLT have been reported between 2006 and 2014, mostly through case reports, case series or case match series (39).
The second international consensus on laparoscopic liver resection (Morioka, Japan) concluded that left lateral sectionectomy for pediatric transplant brought the advantages of minimally-invasive surgery, associated to a safety level not different from open surgery (42). In addition, recent large cohorts published by expert teams show excellent outcomes and recommend the laparoscopic approach as a gold standard for left lateral section retrieval for LDLT (17,18). However, in the setting of adult-to-adult LDH, the experts recommended the creation of a registry to evaluate the benefit/risk ratio, and the Jury did not recommend broad introduction since its safety was not proven yet.
Undoubtedly, major laparoscopic LDH requires a high level of technical skills and has a steep learning curve, restraining its practice to expert teams. However, growing surgeon experience, continuous technical refinements and increasing standardization efforts participate in its diffusion an acceptance.
Donor evaluation process
The selection of an eligible donor means the evaluation of, in one hand, the technical feasibility, and in the other hand, the operative risk for the donor. Such issues imply an extensive workup procedure, including extensive detection of any medical contra-indication, donor psychological assessment, and suitability of the intended graft in terms of anatomy, volume and function.
Donor operative risk evaluation
Currently, there is no consensus for donor age, and we rely more on physiological age than biological age. However, an upper age limit is arbitrarily set at 55 in many centers. Every eligible donor has to be informed about the risks involved in the operation, and the recipient mortality estimation (5%), together with donor mortality (0.2%) and morbidity rates (up to 40%), have to be explained. The innovative nature of the pure laparoscopic technique and its impact on these risks has to be underlined.
An extensive medical history interrogation including in particular personal and/or familial history of diabetes mellitus, cardiovascular diseases, pulmonary disease, malignancy, psychological disorders, alcohol consumption and smoking, deep vein thrombosis risk factors (oral contraception use for women) should be conducted. This must be completed by a complete physical examination including BMI and arterial blood pressure measurements. Biological tests include, besides classical blood hematology and biochemistry, complete glycemic and lipidic profile, common viral serology screening (HIV, hepatitis B and C, CMV, VZV), and, in our center, an extensive research for coagulation disorders (factor V Leiden, factor II, antithrombin III, antiphospholipid antibodies, protein C, protein S). Specific markers for malignancy can be added in case of any clinical suspicion.
A psychiatrist should conduct a complete psychological evaluation and the donor case has to be presented for approval by an ethical committee. Last, according to the French Law, all donors give their informed consent, which is recorded by a Judge of the Civilian Court.
Technical feasibility: graft assessment
The graft assessment workup procedure includes multiple imaging evaluations by ultrasound, CT-scan and MRI cholangiography together. CT-scan with 3D vascular reconstruction is mandatory for arterial mapping. The course and size of hepatic artery and detection of anatomical variations such as a right hepatic artery from the superior mesenteric artery or left hepatic artery arising from the left gastric artery are notified (Figure 1). Origin of segment IV hepatic artery should be outlined (from left or right hepatic artery). Portal veins anatomy is also evaluated (Figure 2), in order to identify division abnormalities such as portal trifurcation. Particular attention is paid to hepatic venous drainage (Figure 3).
CT volumetric measurement of the liver remnant and the intended graft should be performed in order to have a safety limit for donor of 30–35% remnant volume, and to ensure of the 0.8% graft to body weight ratio necessary for the recipient (43-46).
At last, we require a magnetic resonance cholangiography, which is nowadays the best imaging to detect biliary anatomy abnormalities (Figure 4). This investigation is fundamental to search for variations as a right posterior or anterior sectorial duct joining the left hepatic duct; such a situation represents a formal contra-indication to the intervention. Position of left hepatic duct division and site of segment IV duct joining should be recognized as well.
We do not routinely perform liver biopsy, nor ERCP or arteriography in our center.
Finally, the decision of acceptance to perform a living donor right hepatectomy is validated in a multidisciplinary expert reunion, where all potential medical contra-indication are considered, and where suitability of the intended graft in terms of anatomy and volume are closely examined.
Surgical technique (Figure 5)
To enhance the donor safety, two senior surgeons may ideally perform this intervention. Any incident that might compromise donor safety or graft integrity should lead to prompt conversion. In our team, we defined these events or criteria of conversion as following: significant bleeding, failure to accurately recognize bile duct anatomy, any vessel injury, and poor exposure leading to slow progression during parenchymal transection. The operation is divided in three main steps: right pedicle dissection, parenchymal transection including bile duct division, and graft extraction. Usually, these steps are performed in rotation between the two surgeons, one performing the pedicle dissection and the other doing the parenchymal transection and graft removal.
The donor is placed in French position, legs apart. Devices to prevent hypothermia (warming coverage) and deep vein thrombosis (compression stockings) are systematically used.
A carbon dioxide pneumoperitoneum is created and maintained at 12 mmHg pressure. Five ports are inserted as shown in Figure 6. The optic port is placed 2 to 3 cm above and laterally to the umbilicus to avoid any tangential vision to the right liver.
A 30° laparoscope is mandatory, in order to have an optimal vision of every parcel of the abdominal cavity, especially to nicely visualize the hepatic vein and to avoid any discomfort in case of tangential dissection area.
Access to the right liver graft and right pedicle preparation
After a general inspection of the liver and the abdominal cavity, the cystic artery and duct are clipped and divided. After opening the hepatic pedicle, the right hepatic artery and right portal vein are dissected free and taped. Cholecystectomy is performed and the round and falciform ligaments are disconnected.
The right part of segment I is separated to expose the anterior side of the inferior vena cava (IVC), with dividing of the small accessory veins arising from segment I. This part of the dissection is performed as high as possible but without reaching the right hepatic vein. No hanging maneuver is performed and we do not mobilize the right liver at that time.
The right portal vein and hepatic artery are briefly clamped in order to visualize the main portal scissure. The middle hepatic vein, which is kept with the left liver, is then identified with intra-operative ultrasound.
The harmonic scalpel is used for the capsule incision and the superficial part of the transection (no more than 1 cm deep in the parenchyma), and we prefer the ultrasonic dissector for deeper transection.
The parenchyma transection follows the Cantlie line, the upward trajectory of the IVC, and the middle hepatic vein, which is previously located using ultrasound. This laparoscopic visualization from below allows the surgeon to follow the IVC throughout the transection, as previously described by our team as the “inferior approach” (48).
The parenchyma is thus divided step by step and the encountered vascular pedicles are identified before clipping and dividing. Vascular elements larger than 2 mm, such as pedicles assigned to segment 4, are dissected free using ultrasonic dissector, taped using PTFE tapes in order to nicely expose both sides of the pedicle that need to be transected, closed using secured Hem-o-lock® clips (non absorbable polymer vascular clips, Weck, Teleflex Medical, Limerick, Pennsylvania, USA), and divided.
Bleeding is controlled only by using bipolar cautery for minor vessels, and clips for larger vascular structures. No vascular clamping is used in order to minimize both donor and graft damage. A transient increase in pneumoperitoneum pressure up to 16 mmHg can be applied, if well tolerated by the donor, to improve bleeding control.
Right bile duct division
After identification of the right bile duct, an intra-operative cholangiography is performed through the cystic duct. The right bile duct is then divided with scissors at the level of a marker thread. No electric cautery should be applied in this step in order to avoid thermal injury of the biliary duct or the hilar plate. Its distal stump is closed using a secured clip.
End of transection and control of the right hepatic vein
After bile duct division, the parenchyma transection is completed and the right hepatic vein is dissected free, controlled and taped. The right liver is then mobilized by cutting the right triangular ligament. At this stage, the graft is only retained by its vessels.
A 10-cm suprapubic incision is made without opening the peritoneum. This allows the insertion of a large bag through a 15-mm port. The right hepatic artery is closed with a secured clip, then the right portal and hepatic veins are closed using a one-sided stapler and then divided. The right liver graft is placed in the bag and removed through the suprapubic incision without muscle section.
The graft is immediately weighed and perfused with a cold preservation solution through the left portal vein, initiating end of warm ischemia time (usually less than 10 min) and beginning of cold ischemia time. The bile ducts are washed with the same preservation solution.
Graft preparation also includes venous outflow optimization. The veins from segments 5 and 8 may be reconstructed using an allogeneic iliac graft from tissue bank. The right hepatic vein stump can be enlarged with a cuff tailored in an iliac conduit from tissue bank.
After re-insufflation, hemostasis and biliostasis are checked. CO2 pneumoperitoneum is completely evacuated to reduce postoperative pain.
We systematically use prophylactic dose of low molecular weight heparin and compression stockings from postoperative day one for the prevention of deep vein thrombosis Proton pump inhibitors are used systematically to prevent gastric ulcer. No postoperative gastric tube is retained.
Oral intake is allowed in the evening of the procedure, and early mobilisation is encouraged on postoperative day one. Particular attention is paid to postoperative pain and appropriate painkillers are prescribed; their efficiency and necessity are reevaluated daily.
Clinical features and biological tests are closely monitored every day; particular attention is paid to pulmonary examination and any sign of pulmonary embolism is carefully sought. Biological liver function is daily assessed by biochemical tests including prothrombin time and serum bilirubin. Any clinical or biological sign of general or liver-related complication is reported.
Hand-assisted and hybrid techniques
Unlike pure laparoscopic approach, hand-assisted procedure uses a hand port through a right subcostal short incision to facilitate the operation, especially retrohepatic IVC dissection (49).
In hybrid procedure, pedicular dissection and liver mobilization are performed using laparoscopy while liver parenchyma transection and specimen extraction are performed through a short (midline or subcostal) incision.
These methods have been described and compared previously (31,50,51). To date, there is no evidence showing the superiority of one technique over the others and the choice of the technique depends on the surgeons’ experience.
In summary, the right liver can be harvested in a living donor through pure laparoscopic approach in highly experienced centers. We believe that its benefits may increase the potential donation rate, based on a growing global acceptance. Accumulating case series report its technical feasibility and comparable outcomes to conventional approach. However, careful validation through larger series is mandatory before laparoscopic right hepatectomy for live donation may be ready for wider diffusion and acceptance. The question of donor safety remains the main concern of live donor liver transplantation, and improved reproducibility of the procedure is needed through standardization and registry studies.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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Cite this article as: Goumard C, Soubrane O, Brustia R, Scatton O. Laparoscopic right hepatectomy for living donation. Ann Laparosc Endosc Surg 2017;2:81.


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Mechanical Ventilation Redistributes Blood to Poorly Ventilated Areas in Experimental Lung Injury.
Cronin JN., Crockett DC., Farmery AD., Hedenstierna G., Larsson A., Camporota L., Formenti F.
OBJECTIVES: Determine the intra-tidal regional gas and blood volume distributions at different levels of atelectasis in experimental lung injury. Test the hypotheses that pulmonary aeration and blood volume matching is reduced during inspiration in the setting of minimal tidal recruitment/derecruitment and that this mismatching is an important determinant of hypoxemia. DESIGN: Preclinical study. SETTING: Research laboratory. SUBJECTS: Seven anesthetized pigs 28.7 kg (SD, 2.1 kg). INTERVENTIONS: All animals received a saline-lavage surfactant depletion lung injury model. Positive end-expiratory pressure was varied between 0 and 20 cm H2O to induce different levels of atelectasis. MEASUREMENTS AND MAIN RESULTS: Dynamic dual-energy CT images of a juxtadiaphragmatic slice were obtained, gas and blood volume fractions within three gravitational regions calculated and normalized to lung tissue mass (normalized gas volume and normalized blood volume, respectively). Ventilatory conditions were grouped based upon the fractional atelectatic mass in expiration (< 20%, 20-40%, and ≥ 40%). Tidal recruitment/derecruitment with fractional atelectatic mass in expiration greater than or equal to 40% was less than 7% of lung mass. In this group, inspiration-related increase in normalized gas volume was greater in the nondependent (818 µL/g [95% CI, 729-908 µL/g]) than the dependent region (149 µL/g [120-178 µL/g]). Normalized blood volume decreased in inspiration in the nondependent region (29 µL/g [12-46 µL/g]) and increased in the dependent region (39 µL/g [30-48 µL/g]). Inspiration-related changes in normalized gas volume and normalized blood volume were negatively correlated in fractional atelectatic mass in expiration greater than or equal to 40% and 20-40% groups (r = 0.56 and 0.40), but not in fractional atelectatic mass in expiration less than 20% group (r = 0.01). Both the increase in normalized blood volume in the dependent region and fractional atelectatic mass in expiration negatively correlated with PaO2/FIO2 ratio (ρ = -0.77 and -0.93, respectively). CONCLUSIONS: In experimental atelectasis with minimal tidal recruitment/derecruitment, mechanical inspiratory breaths redistributed blood volume away from well-ventilated areas, worsening PaO2/FIO2.


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Autism spectrum disorders (ASD) are often associated with poor motor control, which depends greatly on postural stability. Firstly, this study examined postural stability in young children with ASD, as little is known about early postural skills in this population. Children with ASD are known to depend considerably on visual cues when maintaining balance. We therefore wished to explore whether visual stimuli would in turn improve postural stability. We recruited 18 children with ASD (aged 6–11) and also 12 age-matched typically developing (TD) children. We measured their baseline postural stability and their ability to maintain balance when provided contingent visual feedback of the movements of their center of pressure. Postural performances were measured with a force platform. Baseline postural stability of children with ASD was significantly reduced compared to TD children, as indicated by higher sway scores. When provided visual feedback, children with ASD improved their balance significantly. We conclude that although deficient postural control in ASD is present in childhood, this may be improved in facilitating settings where children with ASD can rely on visual cues.


Professor alexander argues this discovery is a profound challenge both to the right-wing view that addiction is a moral failing caused by too much hedonistic partying, and the liberal view that. Addiction is the dirty little secret of many families, says natalie blais, parenting strategist with apassionateparentcom parents and adults walk a delicate line talking to kids about addiction . Food addicts are often criticized about their inability to say no to overeating not all food addicts are obese, and not everyone who overeats is a food addict. Melbourne man andrew flinders taylor has vowed to only eat potatoes for the entire year as part of a bizarre project 'spud fit' to overcome an eating addiction and change the way he thinks about food.
The reason for this is that money becomes the means the addict makes purchases of more drugs to feed the addiction because the addict is a person who has learned the fine art of manipulation to get what he wants, he knows how to convince loved ones to provide the money he needs to make more drug purchased. Food addiction counseling during which the food addict will receive professional help from a counselor or therapist who specializes in food addiction treatment identification of trigger foods this is the process of getting to know which foods that individual is addicted to and cannot seem to get enough of. Recovery food plan by kay sheppard lmhc, ceds here is a food plan that is scientifically sound for food addicts most important is the fundamental fact that abstinence from addictive chemicals is the basic tool of recovery from all addictions. Food addicts anonymous on amazoncom free shipping on qualifying offers written by food addicts for food addicts, this book describes the faa program and a plan for recovery.
Food addiction is, quite simply, being addicted to junk food in the same way as drug addicts are addicted to drugs it involves the same areas in the brain, the same neurotransmitters and many of. Andrew scott zimmern (born july 4, 1961) is an american culinary expert, chef, television personality, radio personality, director, producer, entrepreneur, food. Debbie has a high fat, high salt unhealthy diet she needs to change her ways freaky eaters gets to the heart of the nation's disordered eating habits nutritionist natalie savona and. 5 food addiction symptoms - food addiction is a real condition that causes serious problems for the addict and those who care about the individual these are some of the most common food addiction symptoms. Prayer for food addiction dear heavenly father, you alone, know all my needs, and all my body's needs, having created it food has been my comforter for wayyyy too long food has been my comforter for wayyyy too long.
What is an addiction specialist the american board of medical specialties (abms), in 2016, officially recognized addiction medicine as a medical subspecialty the american medical association (ama), in 1988, granted the american society of addiction medicine a seat, with a vote, in the ama house of delegates. Helping someone overcome a heroin addiction can be incredibly difficult however, social support is a key component of the recovery process, and you can help provide. While differences also exist, an addiction based model of overeating provides a compelling theory for understanding obesity and the difficulties involved in controlling food intake. Talk to someone who can help you, also, there are professionals out there who can help you deal with your addiction before the temptation hits you, there is usually a triggering event, we experience something uncomfortable. The food addiction institute, a non-profit organization that tracks research in the field, defines food addiction as a chemical dependence caused by changes in the brain in reaction to the biochemistry of a specific food, several foods, or volume of food.
The authors conclude that food addiction is a misnomer, proposing instead the term eating addiction to underscore the behavioural addiction to eating they argue that future research should try to define the diagnostic criteria for an eating addiction, so that it can be formally classified as a non-substance related addictive disorder. A food addiction or eating addiction is a behavioral addiction that is characterized [jargon] by the compulsive consumption of palatable (eg, high fat and high sugar) foods which markedly activate the reward system in humans and other animals despite adverse consequences. For centuries, addiction to alcohol and drugs has been seen as a moral failing the person addicted was viewed as lacking in willpower but while that view is still held by some individuals, a new model for understanding addiction has risen to the forefront in the scientific community.
Porn addiction is considered a behavioral addiction that is characterized by an ever-growing compulsion to view pornographic content or material in the past, a person suffering from an addiction to pornography would primarily satisfy his or her craving for pornographic content by viewing or storing. Optimistic food addict optimisticfoodaddictcom is a website devoted to supporting recovery from food addiction and binge eating disorder christina greeer, phd, the founder and editor of this site, is not a physician but a writer and food addict who aims to help all. The evidence has shown me, however, time and again, even to this day, that i am still a food addict and food addicts are always in recovery, always just one mouthful away from the next binge. Addiction is a very common struggle in america today we're addicted to drugs, alcohol, gambling, sex, pornography, food, and smoking you name it and many people who want to overcome their addiction think that simply having enough willpower is enough for them to stop their addiction but this is.


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From United States Representative Claudia Tenney:
For Immediate Release
June 19, 2018
Congresswoman Tenney’s Bill the Expanding Oversight of Opioid Prescribing and Payment Act Passes the House
Washington, DC— Today, Congresswoman Claudia Tenney (NY-22) announced her bill, H.R. 5723, the Expanding Oversight of Opioid Prescribing and Payment Act of 2018was passed unanimously in the U.S. House of Representatives. This bipartisan legislation requires the Medicare Payment Advisory Commission (MedPAC) to evaluate and report on adverse incentives that lead to the over-prescription of opioids and underutilization of non-opioid alternatives for post-surgery recovery and the treatment of chronic pain. This legislation comes after the House Ways and Means Committee solicited information and ideas to help combat the opioid epidemic. In a report, the Committee noted that many commenters believe that current Medicare policies create unnecessary barriers to the adoption of non-opioid pain treatments.
“In the 22nd district, we lost 114 loved ones to the opioid scourge last year alone—shockingly, this number is nearly 10 percent of the total opioid deaths statewide. Often, an addiction to opioids begins with a prescription for pain management. It’s estimated that up to 29 percent of patients who are prescribed opioids for chronic pain misuse the drug,” said Congresswoman Claudia Tenney, a member of the Bipartisan Heroin Task Force. “Medicare and other insurance providers often do not cover non-opioid alternatives for pain and my bipartisan, common-sense legislation seeks to understand why this is the case. It recognizes barriers that have inhibited the use of non-opioid alternatives and identifies current practices preventing the use of non-opioid treatments for pain management while determining incentives that have unintentionally led to the over-prescription of opioids. I will continue to work to ensure we bring forth meaningful solutions that will end this epidemic and make our families and communities whole again.”
From Majority Leader McCarthy: “Combating America’s deadliest drug crisis will take everything we have. This bill creates critical oversight and increases access to necessary data for the Medicare Payment Advisory Commission to better serve those most in need. Claudia’s work will allow us to continue our fight against the opioid crisis well into the future.”
View Rep. Tenney’s remarks here.


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Indigenous Ear Health - AMA Calls for action to end a 'life sentence' of harm
AMA Indigenous Health Report Card 2017: A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities
The AMA today issued a challenge to all Australian governments to work with health experts and Indigenous communities to put an end to the scourge of poor ear health – led by chronic otitis media – affecting Aboriginal and Torres Strait Islander Australians.
At the launch of the 2017 AMA Indigenous Health Report Card in Canberra today, AMA President, Dr Michael Gannon, said the focus on ear health was part of the AMA’s step by step strategy to create awareness in the community and among political leaders of the unique and tragic health problems that have been eradicated in many parts of the world, but which still afflict Indigenous Australians.
The Report Card – A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities – was launched by the Minister for Indigenous Health, The Hon Ken Wyatt AM.
“It is a tragedy that, in 21st century Australia, poor ear health, especially chronic otitis media, is still condemning Indigenous people to a life sentence of hearing problems – even deafness,” Dr Gannon said.
“Chronic otitis media is a disease of poverty, linked to poorer social determinants of health including unhygienic, overcrowded conditions, and an absence of health services.
“It should not be occurring here in Australia, one of the world’s richest nations. It is preventable.
“Otitis media is caused when fluid builds up in the middle ear cavity and becomes infected.
“While the condition lasts, mild or moderate hearing loss is experienced. If left untreated, it can lead to permanent hearing loss.”
Dr Gannon said that, for most non-Indigenous Australian children, otitis media is readily treated.
“The condition in the non-Indigenous population passes within weeks, and without long-term effects.
“But for many Aboriginal and Torres Strait Islander children, otitis media is not adequately treated. It persists in chronic forms over months and years. At worst, it is there for life.”
Estimates show that an average Indigenous child will endure middle ear infections and associated hearing loss for at least 32 months, from age two to 20 years, compared with just three months for a non-Indigenous child.
Dr Gannon said the AMA wants a national, systematic approach to closing the gap in the rates of chronic otitis media between Indigenous and non-Indigenous infants and children in Australia.
“We urgently need a coordinated national response to the lasting, disabling effects and social impacts of chronic otitis media in the Indigenous adult population,” Dr Gannon said.
“We urge our political leaders at all levels of government to take note of this Report Card and be motivated to act to implement solutions.”
The AMA calls on Australian governments to act on three core recommendations:
That a coordinated national strategic response to chronic otitis media be developed by a National Indigenous Hearing Health Taskforce under Indigenous leadership for the Council of Australian Governments (COAG). This should build on and incorporate existing national and State and Territory level responses and include:
- a critical analysis of current approaches, and to identify the range of reasons that current chronic otitis media crisis persists;
- the development of a COAG Closing the Gap target about new cases of chronic otitis media and hearing loss in Indigenous infants and children under 12 years of age;
- a national otitis media surveillance program to monitor prevalence and support a targeted and cost-effective national response;
- a significantly increased focus on prevention - both primordial prevention with a focus on the social determinants of the disease, and primary prevention including family and community health literacy about otitis media;
- a central, adequately funded and supported role for primary health care and Aboriginal Community Controlled Health Services (ACCHS) in a systematic approach to the prevention, detection, treatment, and management of otitis media; and
- access to ear, nose and throat (ENT) specialists, particularly within ACCHS and other Indigenous-specific primary health care services, based on need.
That the national approach proposed in Recommendation 1 include addressing the wider impacts of otitis media-related developmental impacts and hearing loss, including on a range of areas of Indigenous disadvantage such as through the funding of research as required. This includes:
- a national approach to supporting Indigenous students with hearing loss that aims to remove disadvantage that they may face in educational settings;
- a national approach to developing hearing loss-responsive communication strategies in all government and non-government agencies providing services to Indigenous people including - but not limited to - health, mental health, justice, and employment services; and
- exploring the support role of the National Disability Insurance Scheme (NDIS) to Indigenous people with hearing loss.
That attention of governments be re-directed to the recommendations of the AMA’s 2015 Indigenous Health Report Card, which called for an integrated approach to reducing Indigenous imprisonment rates by addressing underlying causal health issues (including otitis media and related hearing loss and developmental impacts), with the expectation of appropriate action. The health issues to be addressed include mental health problems, cognitive disabilities, alcohol and drug problems, hearing loss, and developmental impacts associated with otitis media.
- Indigenous children experience some of the highest rates of chronic suppuratives otitis media (CSOM) in the world.
- Chronic otitis media in infancy and childhood can affect Indigenous peoples’ adult health and wellbeing as much as cardiovascular disease or diabetes, and its effects are significant ‘life sentences’ of disability.
- Chronic otitis media has life-long impacts that bring greater risk of a range of adult social problems, not the least of which is incarceration. The association of chronic otitis media-related hearing loss and the high rates of Indigenous imprisonment has been noted for over 25 years now – but with little action evident.
The AMA Indigenous Health Report Card 2017 – A National Strategic Approach to Ending Chronic Otitis Media and its Life Long Impacts in Indigenous Communities– is at https://ama.com.au/article/2017-ama-report-card-indigenous-health-national-strategic-approach-ending-chronic-otitis
29 November 2017
CONTACT: John Flannery 02 6270 5477 / 0419 494 761
Maria Hawthorne 02 6270 5478 / 0427 209 753
Follow the AMA Media on Twitter: http://twitter.com/ama_media
Follow the AMA President on Twitter: http://twitter.com/amapresident
Follow Australian Medicine on Twitter: https://twitter.com/amaausmed
Like the AMA on Facebook https://www.facebook.com/AustralianMedicalAssociation
Published: 29 Nov 2017


Some Danish and German children are undergoing invasive surgery to “normalise” their gender.
Human rights group Amnesty International has launched a report examining how some children born with sex characteristics that do not fit in with gender norms are undergoing unnecessary and traumatising medical procedures.
The First, Do No Harm campaign uses case studies from both Denmark and Germany to highlight how gender stereotypes are leading to invasive, irreversible and potentially harmful surgery on children born intersex. Amnesty says such procedures violate their human rights, namely the right to a private life and right to the highest attainable standard of health. Experts from the United Nations have also condemned the practice.
Laura Carter, researcher on sexual orientation and gender identity at Amnesty International, told us:
“These so-called ‘normalising’ procedures are being carried out without full knowledge of the potentially harmful long-term effects they are having on children. We’re talking about incisions being made to sensitive tissue, with life-long consequences, all because of stereotypes about what a boy or girl should look like. The question is whose benefit is this for, because our research shows it has been an incredibly harrowing experience for individuals.”
“The Danish and German authorities are failing in their duty to protect these children. With the current lack of medical research and knowledge in this area, life changing and irreversible decisions should not be being made when the child is too young to have a say in what is being done to them.”
Although in some cases, medical intervention may be necessary to protect the child’s life or health, that is certainly not always the case. The reality is invasive medical procedures are being performed on infants and children, despite the lack of medical research to support their necessity.
Amnesty reports that approximately 1.7% of the worldwide population have variations of sex characteristics. That’s the same amount of people who have red hair.
Some of the people who have undergone these procedures have spoken out about the physical and mental pain they have suffered.
Sandrao from Germany said:
“When I was five I had surgery to remove testicles. I had other operations, other genital surgery. I don’t know if I had a vagina at birth or if it was a reconstruction. My urethra is a different position. I saw a gynaecologist in 2014 and there is a lot of scarring. I knew I was different, I thought I was some kind of monster. I was unable to develop a gender identity. I was pressed into the female role, I had to wear skirts, I had to have long hair. It was painful to have sex with men and I thought this was normal.”
H from Denmark admitted:
“When I think about what happened, I get upset, because it wasn’t something for anyone else to decide – it could have waited. I get sad when I think about the fact that it is considered necessary to operate on these children, only because other people think it should be done.”
Amnesty is now urging legislators and medical professionals in Germany and Denmark to make sure that no child is subjected to unnecessary treatment of this kind.
They say decisions over what happens to a person’s body should wait until the individual is old enough to meaningfully participate in them. They recommend that medical professionals should be trained on gender and body diversity and that those who have suffered unnecessary medical interventions should be compensated. They also say that authorities must stop perpetuating harmful gender stereotypes.
For more about the First, Do No Harm campaign, visit Amnesty’s website.


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Their efficacy potential to lower HbA1c is in the range between 0.5 and 1.0% and their safety profile is favorable. DPP-4 inhibitors are body weight neutral and they Do inhibitorów DPP-4 należą: sitagliptyna (Merck & Co., nazwa handlowa Januvia) wildagliptyna (Novartis, nazwa handlowa Galvus) saksagliptyna (Bristol-Myers Squibb, AstraZeneca i Otsuka Pharmaceutical Co., nazwa handlowa Onglyza) DPP-4 inhibitor-treated patients achieved lower A1C values, but the difference was small (0.20% - 0.36%) and less than what has been seen with other classes of DM meds in similar trials (e.g. SGLT2 inhibitors, GLP-1 inhibitors).
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DPP-4 inhibitors (technically called dipeptidyl peptidase-4 inhibitors) are a class of diabetes drugs use to treat type 2 diabetes. They do not cause hypoglycemia (low blood sugar) and generally do not cause any weight gain. They are usually prescribed as a secondary treatment in addition to or instead of metformin or sulfonylureas. An inhibitor of dipeptidyl peptidase-4 (DPP-4), a protease that degrades the incretin GLP-1 Incretins are hormones released from the GI tract in response to nutrient ingestion Incretins potentiate glucose-stimulated insulin secretion from beta cells in the pancreas DPP-4 inhibitors are a class of drugs that prolong the action of incretin hormones (see below). DPP-4 degrades numerous biologically active peptides, including the endogenous incretins such as GLP-1 and glucose-dependent insulinotropic polypeptide (GIP). NESINA is a dipeptidyl peptidase-4 (DPP-4) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation of Use: Not for treatment of type 1 diabetes or diabetic ketoacidosis.
With the recent disclosure of data from the CARMELINA cardiovascular outcomes trial (CVOT), which investigated linagliptin, CV and renal outcomes data are now available for four agents in the DPP-4 inhibitor class that are approved in most markets. [DPP-4 inhibitor]. [Article in Japanese] Harashima S, Inagaki N. Now seven compounds of DPP-4 inhibitor are available in Japan. They can be used in any stage of type 2 diabetes if the insulin secretion capacity is retained; first-line choice to third-line choice or combination with insulin therapy. Dipeptidyl peptidase-4 (DPP-4) inhibitors ('gliptins') are a recently introduced class of oral drugs for type 2 diabetes.
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This information is current as of today,
2009-H1N1 influenza (sometimes referred to as novel H1N1 or “swine flu”) is a new virus causing illness in humans. It was first detected in people in the United States in April 2009, and the symptoms resemble those of seasonal flu. The virus spreads from person to person. Although it is sometimes referred to as "swine flu," people cannot catch 2009-H1N1 by eating pork products that have been properly prepared.
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2009-H1N1 Vaccine: HHS/CDC continues to recommend vaccination against influenza. Its website notes that the 2010-2011 seasonal influenza vaccine includes protection against the 2009-H1N1 strain in addition to two other influenza strains currently circulating,
Antiviral Drugs for 2009-H1N1: HHS/CDC recommends the use of oseltamivir and zanamivir (commonly known by their brand names of Tamiflu® and Relenza®) for the treatment of 2009-H1N1 influenza, and, in limited cases, for prevention of 2009-H1N1 influenza. Guidance for using these antiviral drugs may change as researchers learn more about this virus.
Information on the U.S. Government's overall planning and response effort is available at the federal influenza website.
The U.S. Government remains concerned about the possibility of a severe influenza pandemic resulting from changes to existing viruses. The ability of influenza viruses to mutate means there is potential for a highly-infectious but moderate influenza strain, like 2009-H1N1, to mutate to a more lethal strain, or for a highly-lethal strain to mutate to a more infectious strain. The new strain could cause a severe pandemic threatening economic and social structures worldwide. This fact sheet offers information on measures U.S. citizens can take to prepare for and cope with a severe pandemic. It also includes information on the U. S. Government’s efforts to plan for and respond to such a pandemic, should one happen.
Once health authorities confirm the start of a severe pandemic, the State Department will assess whether travel is possible and advisable by considering the availability of transport, the likelihood of infection during travel to the United States, issues surrounding departure or arrival screening, the ability of U.S. health institutions to provide care, and other factors. If travel is not inadvisable, the State Department will urge U.S. citizens to consider returning to the United States while commercial transportation is available. (U.S. citizens will be permitted to re-enter the United States, but the U.S. Department of Health and Human Services/Centers for Disease Control and Prevention (HHS/CDC) may quarantine or isolate incoming travelers based on the traveler's health status, whether travel was from or through an area affected by pandemic influenza, or other public health concerns.)
Note that international transportation options may become very limited or unavailable by the time the outbreak moves beyond initially affected countries. Therefore, the State Department continues its efforts to advise American citizens overseas to consider, well in advance of an outbreak, whether they will return to the United States once a severe pandemic has been officially confirmed, even if the outbreak is in another region. Persons at high risk during a pandemic should carefully consider their options. According to HHS/CDC, those at high risk may include: pregnant women; adults and children who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological, or metabolic disorders (including diabetes mellitus); adults and children who have immunosuppression (including that caused by medications or by human immunodeficiency virus); and adults and children who have any condition (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders or other neuromuscular disorders) that can compromise respiratory function.
Evacuations (including non-combatant evacuation operations (NEOs) supported by the Department of Defense) will be considered only if there is a breakdown in civil order that cannot be contained by local authorities and that further threatens the lives of Americans in a particular country. Even then, such evacuation operations may not be possible or advisable based on other concerns. Note that, if the U.S. Government does coordinate an evacuation operation, private U.S. citizens may be required to find their own transportation to the departure point. Note also that private U.S. citizens are required to reimburse the USG for all costs of their evacuation.
Once commercial transportation options become unavailable, American citizens who are still overseas will likely need to remain there during at least the first wave of the pandemic. U.S. citizens should prepare now for such an eventuality, since there is no reliable way to predict if, or how rapidly, commercial transportation would be disrupted. Information on how to prepare is contained in the flyer “Options During a Pandemic,” which urges that U.S. citizens maintain adequate provisions (e.g., food, drinkable water, medications, etc.) for a pandemic wave or waves that could last from two to twelve weeks.
Due to legal restrictions, the U.S. Department of State cannot provide U.S. citizens with supplies, medications, or medical treatment. Therefore, you should carefully weigh the risks of remaining in country versus the risks of traveling, keeping in mind the potential benefits of returning to the United States. For example, returning to the United States could provide you with greater access to antiviral medications, respirators, face masks, and pandemic vaccine. Traveling could also increase the potential for exposure to the virus and for being stranded in a third country if flights are diverted or cancelled.
If you remain abroad, U.S. Government assistance to you may be limited by conditions, but, if possible, will include communicating with family and friends on your behalf, monitoring quarantine/detention conditions as permitted by local health authorities, arranging for transfers of funds or granting temporary subsistence loans, and providing information regarding the availability of medical care (you will have to pay for this care yourself). You should be aware that the U.S. Government cannot demand your immediate release if you are detained or quarantined abroad in accordance with public health and legal authorities.
A different influenza than H1N1 novel influenza, the H5N1 avian influenza is still a cause for concern. Countries continue to report outbreaks of avian influenza A (H5N1), commonly referred to as "bird flu," in their domestic bird populations. The infection is now endemic in wild bird populations. In addition, countries have reported, on a very limited basis, H5N1 infections in other wild and domestic animals. A small number of confirmed cases of H5N1 among humans have been reported, and approximately 60% of these have resulted in death. More information is available on the WHO website. Please refer to that website for the most current information on countries affected by H5N1 and the number of confirmed human cases and deaths.
The vast majority of reported human infections have resulted from direct contact with avian influenza A (H5N1)-infected poultry. Although there is evidence to suggest very limited human-to-human transmission, primarily in family groups involving close exposure to a critically ill member, there is no evidence to suggest the virus can be easily transmitted from human-to-human in a sustained manner at the present time. However, HHS/CDC, the WHO, and the U.S. Department of State are concerned about the potential for this virus to adapt or mutate into a strain that could cause a severe, highly lethal influenza pandemic.
HHS/CDC advises, if you travel to or live in countries affected by H5N1 influenza, to avoid poultry farms, contact with animals in live food markets, contact with surfaces that appear to be contaminated with feces or fluids from poultry or other animals, and consumption of poultry and eggs that are not thoroughly cooked. If you travel to or live in countries affected by H5N1 influenza, you should consider the potential risks of remaining abroad and should keep up to date on the latest medical guidance in the country you are in (or will travel to) so you can make appropriate plans. Specific information relating to H5N1 influenza, including preventive measures, is available at the HHS/CDC website. Additional information on H5N1 influenza is available at the WHO website.
Quarantines can quickly be established. Some countries have restricted (and often prevented) movement into and out of areas where H5N1 outbreaks occurred in poultry within 24 hours. If the virus evolves into a form that can be easily and repeatedly transmitted from human to human, governments may respond by imposing public health measures that restrict domestic and international movement. This will limit the U.S. Government's ability to assist you in these countries. During a pandemic, such measures may be implemented very quickly.
If you plan to travel to a country that has reported outbreaks of avian influenza A (H5N1), or are concerned about H5N1 influenza, you should monitor the HHS/CDC and WHO websites for up-to-date information. Additional country-specific information can be obtained from the U.S. Department of State website, and from individual Embassy and Consulate web pages. You may also call the Office of Overseas Citizens Services in the United States for the latest travel information. The Office of Overseas Citizens Services can be reached from 8:00 a.m. until 8:00 p.m. Eastern Daylight Time, Monday through Friday, by calling 1-888-407-4747 from within the U.S. and Canada, or by calling (202) 501-4444 from other countries.
H5N1 Vaccine: The Food and Drug Administration approved a vaccine for humans that effectively prevents infection with the H5N1 influenza virus, but is not yet commercially available.
Antiviral Drugs for H5N1: HHS/CDC research shows that antiviral medications such as oseltamivir and zanamivir (commonly known by their brand names of Tamiflu® and Relenza®) may be effective in treating H5N1 if taken early in the infection, although their effectiveness will not be known with certainty until an H5N1 pandemic strain emerges and is analyzed.
Information on the U.S. Government's overall planning and response effort is available at the federal influenza website.
Two of the most common antiviral medications for the treatment of influenza are oseltamivir and zanamivir (also known by their brand names of Tamiflu® and Relenza®).
As with all prescription medications, side effects may occur, and rare-but-serious side effects have been reported with both oseltamivir and zanamivir. You should consult with your healthcare provider and read the package insert approved by the U.S. Department of Health and Human Services/Food and Drug Administration (HHS/FDA) before taking these medications. Expired medications should not be taken.
You can get oseltamivir and zanamivir antiviral medications by prescription from a healthcare provider in the United States. If such medications or adequate medical treatment are not readily available at an overseas location or travel destination, you should discuss with your doctor how to get them before you travel overseas. More information is available at the HHS/CDC Travelers’ Health website.
The U.S. Department of State has positioned supplies of antiviral medications at its Embassies and Consulates for eligible U.S. Government employees and their dependents. However, due to legal restrictions and a lack of sufficient resources, the U.S. Department of State cannot provide private U.S. citizens with supplies, medications, or medical treatment in the event of a pandemic.
You should also be aware of the potential health risks posed by counterfeit drugs, including those represented as oseltamivir or zanamivir by scam artists who sell products on the internet or in countries with lax regulations governing the production and distribution of pharmaceutical products. For more information on counterfeit drugs, please visit HHS/FDA’s website.
Though antiviral medications are an important tool for the treatment and prevention of influenza, according to HHS/CDC, the spread of viral infection can also be reduced by washing hands frequently with soap and water (or an alcohol-based hand cleaner), covering coughs with a tissue, refraining from touching the eyes, nose or mouth, and avoiding close contact with sick individuals.
To reduce the spread of illness, HHS/CDC recommends that you avoid travel if you have flu-like symptoms or are sick with a disease easily spread from person o person. If you have flu-like symptoms, you should follow the guidance of local health authorities for the isolation of sick persons and should not take public transportation for the duration of the infectious period unless medically cleared to do so.
If you remain in a country experiencing a pandemic, you should also limit exposure to the virus through such measures as avoiding mass transit and public gatherings, and you should take the hygienic precautions outlined above. For more detailed information on steps you can take to stay healthy, please visit the HHS/CDC website and the U.S. Government’s federal influenza website.
Complete planning guidance on how you can prepare to remain in a foreign country during a pandemic, including advice on stocking food, water, and medical supplies, is available at the federal influenza website.
Embassy and Consulate Web Pages - http://www.usembassy.gov/
Federal Influenza Website - http://www.flu.gov/
Health and Human Services / U.S. Food And Drug Administration - http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/CounterfeitMedicine/default.htm
The Centers for Disease Control and Prevention (CDC)
1600 Clifton Road
Atlanta, GA 30333
Telephone: (800) 232-4636
TTY: (888) 232-6348
International: (404) 639-3311
The World Health Organization (WHO)
WHO Liaison Office
1889 F Street, NW, Suite 369
Washington, DC 20006
Telephone: (202) 974-3787
U.S. Department of State - http://www.travel.state.gov/travel/travel_1744.html


Hemorrhage From The Lungs
( Originally Published 1921 )
In those suffering from heart trouble hemorrhage from the lungs is not ordinarily dangerous, and is important only as indicating that there is considerable congestion of the lungs. Most sufferers are benefited rather than otherwise by the loss of a fair quantity of blood, and while it is terrifying to have people bleed from the lungs, it ought not to be the cause of undue anxiety. No particular treatment is necessary except to keep them perfectly quiet.
I have observed over a period of many years people who had chronic heart trouble and were rather pleased than otherwise when they had experienced a hemorrhage from the lungs. They always felt so much relieved, and believed that they could look forward to additional comfort for some time.


Krysten Marie Bell, MD is a health care provider primarily located in Boise, ID, with other offices in Nampa, ID and Meridian, ID (and 2 other locations). She has 12 years of experience. Her specialties include Orthopedic Surgery and General Orthopedics.
Graduated in 2010
Dr. Bell graduated from the Loma Linda University School of Medicine in 2010. She works in Boise, ID and 4 other locations and specializes in Orthopedic Surgery and General Orthopedics. Dr. Bell is affiliated with St Luke's Boise Medical Center.