In hydrocephalus, there is a buildup of fluid

Ventriculoperitoneal shunting

Shunt - ventriculoperitoneal; VP shunt; Shunt revision

Last reviewed: November 22, 2010.

Ventriculoperitoneal shunting is surgery to relieve increased pressure inside the skull due to excess cerebrospinal fluid (CSF) on the brain (hydrocephalus).

This article primarily discusses shunt placement in children.

See also: Intracranial pressure

Description

This procedure is done in the operating room under general anesthesia. It takes about 1 1/2 hours.

The child's hair behind the ear is shaved off. A surgical cut in the shape of a horseshoe (U-shape) is made behind the ear. Another small surgical cut is made in the child's belly.

A small hole is drilled in the skull. A small thin tube called a catheter is passed into a ventricle of the brain.

Another catheter is placed under the skin behind the ear and moved down the neck and chest, and usually into the abdominal (peritoneal) cavity. Sometimes, it goes to the chest area. The doctor may make a small cut in the neck to help position the catheter.

A valve (fluid pump) is placed underneath the skin behind the ear. The valve is attached to both catheters. When extra pressure builds up around the brain, the valve opens, and excess fluid drains out of it into the belly or chest area. This helps decrease intracranial pressure.

The valves in newer shunts can be programmed to drain more or less fluid from the brain.

Why the Procedure Is Performed

In hydrocephalus, there is a buildup of fluid of the brain and spinal cord (cerebrospinal fluid or CSF). This buildup of fluid causes higher than normal pressure on the brain. Too much pressure, or pressure that is present too long, will damage the brain tissue.

A shunt helps to drain the excess fluid and relieve the pressure in the brain. A shunt should be placed as soon as hydrocephalus is diagnosed.

Risks

Risks for any anesthesia are:

• 
  
  

  Reactions to medications




• 
  
  

  Problems breathing




• 
  
  

  Changes in blood pressure or breathing rate

Risks for any surgery are:

• 
  
  

  Bleeding




• 
  
  

  Infection

Possible risks of ventriculoperitoneal shunt placement are:

Blood clot or bleeding in the brain

• 
  
  

  Brain swelling




• 
  
  

  The shunt may stop working and fluid will begin to build up in the brain again.




• 
  
  

  The shunt may become infected.




• 
  
  

  Infection in the brain




• 
  
  

  Damage to brain tissue




• 
  
  

  Seizures

Before the Procedure

If the procedure is not an emergency (planned surgery):

• 
  
  

  Tell your doctor or nurse what drugs, supplements, vitamins, or herbs your child takes.




• 
  
  

  Give any drugs the doctor told you to give your child. It is okay if they take them with a small sip of water.




• 
  
  

  The doctor or nurse will tell you when to arrive at the hospital.

Ask your doctor or nurse about eating and drinking before the surgery. The general guidelines are:

• 
  
  

  Older children should not eat any food or drink any milk for 6 hours before surgery, but they can have clear fluids (juice or water) up until 4 hours before the operation.




• 
  
  

  Infants younger than 12 months can usually eat formula, cereal, or baby food until about 6 hours before surgery. They may have clear fluids up until 4 hours before the operation.

Your doctor may ask you to wash your child with a special soap on the morning of the surgery. Rinse well after using this soap.

After the Procedure

Your child will need to lie flat for 24 hours the first time a shunt placed. After that your child will be helped to sit up.

The usual stay in the hospital is 3 to 4 days.The doctor will check vital signs and neurological status often. Your child may get medication for pain. Intravenous fluids and antibiotics are given. The shunt will be checked to make sure it is working properly.

Outlook (Prognosis)

Shunt placement is usually successful in reducing pressure in the brain. But if hydrocephalus is related to other conditions, such as spina bifida, brain tumor, meningitis, encephalitis, or hemorrhage, these conditions could affect the prognosis. The severity of hydrocephalus present before surgery will also affect the outcome.

Support groups for families of children with hydrocephalus or spina bifida are available in most areas.

The major complications to watch for are an infected shunt and a blocked shunt.

References

1. Etiological categories of neurological disease. In: Goetz CG, ed. Textbook of Clinical Neurology. 3rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 28.



2. Kinsman SL, Johnston MV. Congential anomalies of the central nervous system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 592.

Review Date: 11/22/2010.

Reviewed by: Kevin Sheth, MD, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Disclaimer

Copyright © 2011, A.D.A.M., Inc

Alisons Story

I wanted to write about my experience of having Jack and being pregnant. I have recently joined ASBAH's forum on Facebook and I realise how many other people with spina bifida are considering becoming a parent and thought it might be useful to share my experience.

I was 37 when, as a woman with spina bifida I became pregnant for the first time. Although it was a lovely surprise I have to admit it was also quite a shock having been told at the age of 20 I was infertile. Hence the pregnancy was unplanned as I had come to a point of acceptance years before that I wouldn't ever be a mum.

So there I was, standing in my bathroom in a state of disbelief staring at my pregnancy test as the word "pregnant" flashed up. I dropped the test stick in the sink and rushed in to my living room pacing the room. It was a mixture of elation and fear flooding through me all at once. Elation that once again the medical profession had got it wrong just like they told my mum I would probably never walk when I was two years old (I walked at 3 1/2). The realisation that I would in fact be a mum after so many years of believing I wouldn't. Then of course the fear. Fear for the baby as I hadn't been taking folic acid and fear for me. How would the pregnancy affect me and how could I physically cope with being a mum.

My pregnancy was full of professionals who although monitored me as a high risk "mum to be" appeared to have no specialist knowledge of spina bifida. Thank God for ASBAH and the medical advisers who I was really able to talk to and discuss and prepare myself for the way ahead.

My pregnancy wasn't easy. I went from walking without aids to being on crutches and barely able to dress myself at the end and other problems related to my disability worsened. Having said that I look back on the experience fondly and still remember the first time my unborn baby kicked me. It was Boxing Day and it was the best Christmas present I could ever have.

At 20 weeks pregnancy came a bit of a blow. My scan showed that my baby had talipes. They had been looking for spina bifida and had ruled it out up to then but since I too have talipes (clubfoot) and it can be associated with spina bifida I was told that they had to suspect that the baby could have some form of spina bifida even though they couldn't see it. Again I was fearful. Having a baby was going to be physically demanding enough for me but having a baby who also had physical problems to deal with seemed overwhelming. From then on I was scanned regularly until 30 weeks.

On 11th June 2008 I gave birth to my beautiful son Jack. He was born by emergency caesarean nearly 2 weeks overdue after I had been induced and he had gone into distress during labour. I have to say that one of the positive aspects of being a spina bifida mum in labour was that pain didn't scare me nor did medical intervention. The big disappointment was that my spina bifida meant that my caesarean had to be performed under general anaesthetic rather than a spinal anaesthetic so I wasn't awake to see him come into the world.

When I woke up I peered across the room to see my partner Michael holding this bundle in his arms. He brought him over to me and the midwife put him straight to my breast. It was love at first sight. I soon discovered why my labour hadn't progressed so well. He weighed in at 8 pound 14 oz and I'm only 4 ft 9 inches tall! My advice to other mums to be in my position is to push for a 36-week scan to estimate the baby’s size. I was offered one but was told it was optional and therefore didn’t have one as I’d had so many during my pregnancy. I think if I'd had one at that point they wouldn't have let me go overdue and the birth would have been a lot less traumatic for all of us whether it had been a planned Caesarean or a pre term vaginal delivery.

Jack started treatment for his clubfoot at 13 days old when he was put in plaster. His foot was gradually straightened using a series of weekly plasters, a small op and the boots and bars. He will have to wear them at night until he is 4 years old.

Jack doesn't have spina bifida. He was 10 weeks old before they finally ruled it out. I was relieved because even though I've achieved everything I have wanted to in life I'm glad he won't have to go through the operations and pain I had to put up with. And when he is 4 years old his foot will be completely corrected.

Caring for Jack through his treatment has been emotionally hard for me. Going to Great Ormond Street, albeit a fantastic hospital, bought back memories of my childhood that I would have rather left behind me. It's also been physically very challenging for me, as Jack is very tall and heavy for his age. My initial reservations about asking for help have subsided and I have managed to get some good support from occupational therapy in looking for equipment that will help me and strategies in helping me to get Jack be a bit more cooperative during change times so he doesn't fight and run away from me but gets rewarded for sitting still. I think though that asking for help has been the hardest aspect of being a new mum as I've fought all my life for maximum independence. You have to remember though that all new mums need help and not feel as though it's the disability getting the better of you.

A positive aspect of being a disabled mum is that I feel I am so much more used to assessing the risks that could be present for Jack. When you have a disability you have to plan ahead when you are going out and know your limitations. These become a way of life for a physically disabled person and they are excellent attributes to have as a mum. Also I've noticed how much of a shock it is to new able-bodied mums: having to think about ramps and access for buggies. Even though I walk independently I'm used to looking for lifts, handrails and ramps so a new pram didn't feel like a new obstacle; in fact it helped me get back on my feet by offering me something to hold on to... The best walking aid ever.... a pram with your new baby in it.

There are days when Jack is having tantrums that he makes me feel very physically inadequate. If he decides to run off and lie down on the ground in a temper there is nothing I can do to stop him. But I think every mum goes through these feelings so I try not to let it get to me. I know that all Jack really needs is love and affection. My disability is as insignificant to him as his foot problems are to me. They are just part of who we are and if anything add to the bond we have with each other.

Alison has spina bifida and is mum to Jack who is 2 years old.

Meningocele repair

Myelomeningocele repair; Myelomeningocele closure; Myelodysplasia repair; Spinal dysraphism repair; Meningomyelocele repair; Neural tube defect repair; Spina bifida repair

Last reviewed: February 9, 2011.

Meningocele repair (also known as myelomeningocele repair) is surgery to repair birth defects of the spine and spinal membranes. Meningocele and myelomeningocele are types of spina bifida.

Description

For both meningoceles and myelomeningoceles, the surgeon will close the opening in the back.
After birth, the defect is covered by a sterile dressing. Your child may then be transferred to a neonatal intensive care unit (NICU) and cared for by a medical team experienced in caring for children with spina bifida.
Your baby will likely have an MRI (magnetic resonance imagining) or ultrasound of the back. An MRI or ultrasound of the brain may be done to look for hydrocephalus (extra fluid in the brain).
If the myelomeningocele is not covered by skin or a membrane when your child is born, surgery will happen within 24 to 48 hours after birth to prevent infection.
If your child has hydrocephalus, the doctor may put a shunt (plastic tube) in their brain to drain the extra fluid to the stomach. This prevents pressure that could damage the baby’s brain. See also: Ventriculoperitoneal shunt
Your child should not be exposed to latex before, during, and after surgery. Many of these children have very bad allergies to latex.

Why the Procedure Is Performed

Repair of a meningocele or myelomeningocele is needed to prevent infection and further injury to the child’s spinal cord and nerves. Surgery cannot correct the defects in the spinal cord or nerves.

Risks

Risks for any anesthesia are:

• Breathing problems
• Reactions to medications

Risks for any surgery are:

• Bleeding
• Infection

Risks for this surgery are:

• Fluid build up and pressure in the brain (hydrocephalus)
• Increased chance of urinary tract infection and bowel problems
• Infection or inflammation of the spinal cord
• Paralysis, weakness, or sensation changes due to loss of nerve function

Before the Procedure

A health care provider often will find these defects before birth using fetal ultrasound. The doctor will follow the fetus very closely until birth. It is better if you're infant is carried to full term. Your doctor will want to do a cesarean section (C-section). This will prevent further damage to the sac or exposed spinal tissue.

After the Procedure

Your child will usually need to spend about 2 weeks in the hospital after surgery. The child must lay flat without touching the wound area. After surgery, your child will receive antibiotics to prevent infection.
MRI or ultrasound of the brain is repeated after surgery to see if hydrocephalus develops once the defect in the back is repaired.
Your child may need physical, occupational, and speech therapy. Many children with these problems have gross (large) and fine (small) motor disabilities, and swallowing problems, early in life.
The child may need to see a team of medical experts in spina bifida often after they are discharged from the hospital.

Outlook (Prognosis)

How well a child does depends on the initial condition of their spinal cord and nerves. After a meningocele repair, children often do very well and have no further brain, nerve, or muscle problems.
Children born with myelomeningocele usually have paralysis or weakness of the muscles below the level of their spine where the defect is. They also may not be able to control their bladder or bowels. They will likely need medical and educational support for many years.
The ability to walk and control bowel and bladder function depends where the birth defect was on the spine. Defects lower down on the spinal cord may have a better outcome.

References

1. Kinsman SL, Johnston MV. Congenital anomalies of the central nervous system. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 592.

Review Date: 2/9/2011.

Reviewed by: Luc Jasmin, MD, PhD, Department of Neurosurgery at Cedars-Sinai Medical Center, Los Angeles, and Department of Anatomy at UCSF, San Francisco, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc

myelomeningocele and this is the type of spina bifida that will be referred to whenever the term spina bifida is used

Introduction

Children with disability

Dr Sheila Shribman talks about how parents and health professionals can work together to support children with disability.

Spina bifida occulta

Spina bifida occulta is the least serious type of spina bifida. In this type of spina bifida, the opening in the spine is very small, with a gap in one or more vertebrae (disc-shaped bones of the spine). The opening in the spine is covered with skin, so the gap is not visible from the outside.

Spina bifida occulta does not usually cause any symptoms and most people are unaware that they have the condition. In such cases, no treatment is required. In other cases, some symptoms may be apparent, such as bladder and bowel problems, or scoliosis, which is an abnormal curvature of the spine.

Spina bifida meningocele

Spina bifida meningocele is the rarest type of spina bifida. In this type of spina bifida, the meninges, which are the protective membranes that surround the spinal cord, are pushed out between openings in the vertebrae. The membranes can usually be removed during surgery and no further treatment is required.

In spina bifida meningocele, the nervous system is undamaged. However, a person with meningocoele may develop other problems, including bladder and bowel problems.

Spina bifida is a term that is used to describe a series of birth defects that affect the development of the spine and central nervous system. The central nervous system is made up of the brain, nerves and spinal cord. The spinal cord runs from the brain to the rest of the body and consists of nerve cells and bundles of nerves that connect all parts of the body to the brain.

The neural tube

During the first month of life, an embryo (developing baby) grows a primitive tissue structure called the neural tube. As the embryo develops, the neural tube begins to change into a more complicated structure of bones, tissue and nerves that will eventually form the spine and nervous system.

However, in cases of spina bifida, something goes wrong with the development of the neural tube and the spinal column (the ridge of bone that surrounds and protects the nerves) does not fully close. Spina bifida is a Latin term that means split spine.

Types of spina bifida

There are different types of spina bifida, including:

• spina bifida occulta
• spina bifida meningocele
• myelomeningocele

This article focuses on myelomeningocele and this is the type of spina bifida that will be referred to whenever the term spina bifida is used. See the box to the left for information about spina bifida occulta and spina bifida meningocele

Myelomeningocele

Myelomeningocele is the most serious type of spina bifida. It is estimated that it affects one baby in every 1,000 that are born in Britain.

In myelomeningocele, the spinal column remains open along several vertebrae (the disc-shaped bones that make up the spine). The membranes and spinal cord push out to create a sac in the baby’s back. Sometimes the sac is covered with membranes called meninges, although it often remains open, leaving the nervous system vulnerable to infections that may be fatal.

In most cases of myelomeningocele, surgery can be carried out to close the defect. However, extensive damage to the nervous system will usually have already taken place. Damage can result in a range of symptoms including:

• partial or total paralysis of the lower limbs
• bowel incontinence and urinary incontinence
• loss of skin sensation

Most babies with myelomeningocele will also develop hydrocephalus, which is a condition where there is excess cerebrospinal fluid (CSF). CSF is the fluid that surrounds the brain.

The build-up of CSF is caused by problems with the development of the neural tube. Hydrocephalus needs to be treated with surgery because the extra pressure that the fluid places on the brain can cause brain damage.

See the Health A-Z topic about Hydrocephalus for more information about the condition.

Outlook

Over recent years, advancements in the treatment of spina bifida have resulted in a more positive outlook for the condition.

For example, before the 1960s, most children with spina bifida would die during their first year of life. However, today it is likely that children will survive into adulthood. Spina bifida can be a challenging condition to live with, but many adults with the condition are able to lead independent and fulfilling lives.

See Spina bifida - treatment for information about the range of different techniques that can be used to treat the condition.

Show glossary terms

Bacteria stops dengue in tracks

The researchers infected the mosquito Aedes aegypti with bacteria

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• 'Bug' could combat dengue fever
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Australian scientists say they have discovered a cheap and effective method of preventing the transmission of dengue fever.

They infected mosquitoes that spread the disease with bacteria that block transmission of the dengue virus.
When the resistant insects were released, they successfully interbred with wild mosquitoes and halted their ability to transmit dengue.
Details of the work are published in the journal Nature.
The researchers are hopeful that this could be a viable control for a disease that affects more than 50 million people worldwide every year.
According to the World Health Organization around one third of the world's population is at risk from dengue fever. The incidence and severity of this untreatable, mosquito-borne illness are increasing in many parts of the world.
Pesticides that kill the specific type of mosquitoes that carry the virus have been the most effective method of control to date, but resistance is rising.
Now a team of Australian scientists say that a simple bacterium called Wolbachia that only infects insects could stop dengue in its tracks.
Natural agent
Professor Scott O'Neill from Monash University, Melbourne, is one of the authors of the research.
"The approach is to use a naturally occurring bacterial agent - An intracellular bacteria that only grows within insects, and it's extremely common in the environment, up to 70% of insects naturally carry it."
After a series of laboratory experiments that proved the power of Wolbachia to restrict the abilities of mosquitoes to transmit dengue, the scientists then released several hundred thousand of them in Queensland in northeastern Australia.
Scott O'Neill explained that a critical aspect was getting the consent of the community to the idea of releasing even more mosquitoes into the environment.
"We spent a considerable amount of time preparing the community before we did the open field tests. A key component was an independent risk analysis undertaken by the CSIRO (Commonwealth Scientific and Industrial Research Organisation - Australia's national science agency). It indicated that over a 30 year time frame any potential for a negative risk with these experiments was considered negligible," he said.
"The mosquitoes were placed in containers, we filled up a van with these containers and drove around early in the morning in the neighbourhood and simply lifted the cover off these containers and the mosquitoes would fly out."
Within months, a wave of infection by the bacterium had spread to almost all the wild mosquitoes rendering them incapable of passing on dengue.
The scientists are uncertain as to why Wolbachia blocks the ability to transmit dengue, but Professor O'Neill said they have two theories: "The first relates to the immune system. The data suggests that the presence of Wolbachia boosts the immune system and helps the mosquito fight off the effects of dengue.
"Other evidence suggests that Wolbachia is competing for key sub-cellular molecules that the virus needs to replicate such as fatty acids - the jury is still out, it might be a combination of both."
The researchers say that further field tests are needed in countries like Thailand, Vietnam, Brazil and Indonesia where the disease is endemic.

More on This Story

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• 'Bug' could combat dengue fever 02 JANUARY 2009, HEALTH
• Blame game amid Rio dengue crisis 01 APRIL 2008, AMERICAS

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Designer vagina

Designer vagina NHS operations unwarranted

Women seek labial reduction surgery for cosmetic reasons

Published on 24/08/11

Women with normal sized labia minora still seek labial reduction surgery for cosmetic reasons finds new research published today in BJOG: An International Journal of Obstetrics and Gynaecology.

Women with normal sized labia minora still seek labial reduction surgery for cosmetic reasons finds new research published today (24 August) in BJOG: An International Journal of Obstetrics and Gynaecology.

Female cosmetic genital surgery is increasingly popular and the number of labial reduction procedures in the National Health Service has increased five fold in the past 10 years.

This is the first study looking specifically at the labial dimensions of women seeking cosmetic surgery. It looked at 33 women who had requested labial reduction surgery and who had been referred by their general practitioner. The average age of the group was 23.

All of the women were examined by a gynaecologist and the width and length of the labia minora were measured and compared with published normal values.

The study found that all women seeking surgery had normal sized labia minora, with an average width of 26.9 mm (right), and 24.8 mm (left).

Three women out of the total number were offered surgery to address a significant asymmetry. Of the women who were refused surgery, 12 (40%) of the women still remained keen to pursue surgery by another route, 11 women accepted a referral for psychology and one participant was referred to mental health services.

The women were asked what they would like to achieve with surgery and 20 women (60%) wished to make the labia smaller to improve appearance. Other reasons included reducing discomfort, improving confidence and wanting to improve sexual intercourse.

The study also looked at how old the women were when they first became dissatisfied with the labia minora. Twenty-seven women (81%) were able to pinpoint this. Of these, 5 women (15%) reported this to be under the age of 10, 10(30%) between the ages of 11 and 15, 5 (15%) between 16 and 20, 4 (12%) in their twenties, and 3 (9%) in their thirties.

Reasons for this dissatisfaction included an increasing self awareness of the genital area, physical discomfort, comments from a partner and watching TV programmes on cosmetic genital surgery.

Sarah Creighton, UCL Elizabeth Garrett Anderson Institute of Women’s Health and lead author said:

“It is surprising that all of the study participants had normal sized labia minora and despite this nearly half were still keen to pursue surgery as an option.

“A particular concern is the age of some of the referred patients, one as young as 11 years old. Development of the external genitalia continues throughout adolescence and in particular the labia minora may develop asymmetrically initially and become more symmetrical in time.”

BJOG Deputy Editor-in-Chief, Pierre Martin-Hirsch, added:

“Many women who are worried may have normal sized labia minora. Clear guidance is needed for clinicians on how best to care for women seeking surgery.”

About 2,000 genital cosmetic operations are paid for by the NHS each year

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• Designer vagina trend 'worrying'

GPs should not refer women who are well but worried for female genital cosmetic surgery on the NHS, say experts.

Specialists at a Central London teaching hospital say they received 30 such referrals, mainly from family doctors, over the past three years.

This included eight schoolgirls - one as young as 11 - the British Journal of Obstetrics and Gynaecology reports.

Experts say doctors need clear guidance on how best to care for women who mistakenly believe they need surgery.

The British Association of Aesthetic Plastic Surgeons says medics need to determine whether a problem exists or whether an alternative solution may be preferable, but offers no advice on how to judge the problem, say the researchers from University College London's Women's Health Institute.

Continue reading the main story

“Start Quote

It's shocking, particularly because we are seeing girls who are really young”

End Quote Lead investigator Dr Sarah Creighton

They say it may be simpler to ban the procedure in the NHS altogether, leaving it to private practices. Some Primary Care Trusts do this.

And private provider Bupa says the procedure is purely cosmetic and does not offer financial cover for the procedure.

The NHS has no such restriction.

The experts who carried out the latest work said: "A private medical insurance company seems to be able to come to a conclusion when professional bodies are reluctant to act.

"National care standards are urgently needed."

Boom industry

Dr Sarah Creighton and colleagues believe the future demand for so-called "designer vagina" operations or labial reductions is potentially infinite and is driven by society's wider and growing desire for cosmetic surgery in general and changing expectations about what is a desirable appearance for women.

"It's shocking, particularly because we are seeing girls who are really young. They are asking for surgery that is irreversible and we do not know what the long-term risks of the procedure might be."

She said latest figures for England show about 2,000 of the procedures are paid for by the NHS each year.

"That's probably just the tip of the iceberg. It's a massive boom industry in the private sector."

For the study, they reviewed all 33 women referred to their clinic between 2007 and 2010 with requests for a labial reduction.

Most of the women were seeking help because they were concerned about appearance. Only a fifth wanted the surgery to reduce discomfort. One woman said she felt compelled to have the surgery after seeing a television programme on cosmetic genital surgery.

Continue reading the main story

“Start Quote

If the concerns are aesthetic, that should probably be seen in the private sector”

End Quote Paul Banwell British Association of Aesthetic Plastic Surgeons

A third of the women said they had looked at advertisements about the surgery before seeing a doctor.

Upon examination, all of the women were deemed to have "normal" genitalia by the doctors. But three were offered surgery to address "a significant asymmetry". The remaining 30 were refused any procedure.

All of the women were offered the options of sessions with a clinical psychologist to explore issues leading to their request for surgery.

Twelve of the women said they would be seeking a second opinion and would consider going private to get the surgery if they still could not get it on the NHS.

Paul Banwell, of the British Association of Aesthetic Plastic Surgeons, said the operation was merited for some women, particularly those with functional concerns like discomfort.

"But if the concerns are aesthetic, that should probably be seen in the private sector."

He said he often dissuades patients from having the surgery and explains to them that there is a spectrum of 'normal' when it comes to female anatomy.

"We welcome the opportunity to be involved in suggesting guidelines and help for healthcare professionals seeing patients who are interested in labiaplasty."

More on This Story

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• Designer vagina trend 'worrying' 23 SEPTEMBER 2008, HEALTH

Related Internet links

• British Journal of Obstetrics and Gynaecology

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• BBC Health: Cosmetic surgery

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PFI projects 'poor value for money',

say MPs

PFI projects will generate an estimated £2.8bn in capital spending this year

The Private Finance Initiative (PFI) used by successive governments to pay for new schools and hospitals is poor value for money, MPs have said.

The Treasury select committee said PFI was no more efficient than other forms of borrowing and it was "illusory" that it shielded the taxpayer from risk.
Government had become "addicted" to PFI, the committee's Tory chair said.
A government source said it had already acted to make PFI more transparent and rigorous and cut the cost of projects.
Following criticism that the true costs of PFI were being hidden "off balance sheet" and excluded from government debt calculations, the coalition published details of total PFI liabilities for the first time last year alongside the national accounts.
PFI was introduced by John Major's Conservative government in 1992 as a way of bringing in private funding to pay for major public infrastructure projects.
'Addicted'
It was widely used by Labour between 1997 and 2010 but faced growing criticism for the costs involved and the ultimate liabilities for the taxpayer in the event of projects going wrong - such as the collapse of London Underground maintenance firm Metronet in 2008.
In a critical report, the cross-party Treasury select committee said the long-term expense of PFI deals - where the private sector shoulders the upfront cost and is typically repaid by the taxpayer over a 30-year period - were now much higher than more conventional forms of borrowing.
Due to the financing costs involved, it said paying off a £1bn debt incurred through PFI cost the taxpayer equivalent to a direct government debt of £1.7bn.
PFI had become the default option for many public bodies as initial procurement costs were comparatively low, the MPs said, but too often the size of the financial commitments undertaken and their impact on future budgets was not taken into account at the time.
"We believe that a financial model that routinely finds in favour of the PFI route, after the significant increases in finance costs in the wake of the financial crisis is unlikely to be fundamentally sound," the report concluded.
"We do not believe that PFI can be relied upon to provide good value for money without substantial reform."

“Start Quote

PFI means getting something now and paying later”

End Quote Andrew Tyrie Treasury committee chairman

The report found little evidence that PFI-funded buildings were of higher quality or more innovative in their design than those procured by other means or that contractors were incentivised to maintain finished buildings to a higher standard.

"PFI means getting something now and paying later," Andrew Tyrie, the Tory MP who chairs the committee, said.
"Any Whitehall department could be excused for becoming addicted to that. We cannot carry on as were are, expecting the next generation of taxpayers to pick up the tab. PFI should only be used where we can show clear benefits for the taxpayer."
''Much-needed'
An aide to the chancellor said the government had already taken action to ensure a "level playing field" between PFI and other public procurement methods and to address some of the "perverse incentives" surrounding PFI identified by the committee.
"We have been saying for a long time that the PFI system we inherited was completely discredited," he said. "That's why we are reforming it so it is genuinely transparent and only used when it provides value for money for the taxpayer.
"So far we have announced plans to save £1.5bn off existing projects, abolished PFI credits so PFI doesn't have an advantage over other forms of public procurement and strengthened the approval process for approving projects."
Labour defended its use of the PFI system when it was in government, saying it had been used to deliver hundreds of new public facilities and the biggest ever hospital building programme.
Kerry McCarthy, Labour's shadow treasury minister, said clear guidelines were in place to ensure it was only used if it was deemed value for money compared with public sector routes.
"The Tory-led government has continued to use the PFI scheme, the Treasury has reportedly signed off on more than 60 projects so far totalling close to £7bn," she said.
"This suggests that they believe it can be a value for money means of generating investment in our public services."
The CBI said the government needed to decide how PFI would develop in the future as investors needed certainty and the economy badly needed private investment.
"With the state of the public finances, it is absolutely essential we attract the billions of pounds of private finance needed to upgrade our national infrastructure and boost jobs and growth," said its deputy director general Neil Bentley.
"It is worth remembering that without PFI we would not have seen hundreds of much-needed hospitals, schools and homes delivered on time and within budget."

how the body stops C. diff from being toxic

Gut's hospital bug defence found

Researchers show how the body stops C. diff from being toxic

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• Q&A: Clostridium difficile
• C. diff rise due to 'gene switch'
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The way cells in the gut fight off toxins produced by a hospital bug has been discovered by US researchers.

Writing in Nature Medicine, they showed how a chemical - GSNO - deactivated a toxin from Clostridium difficile which causes inflammation and diarrhoea.

They hope to use their findings to develop a treatment for C. difficile.

A specialist in the bacterium said the discovery was "exciting", but any treatment was still a long way off.

C. difficile is one of many bacteria which can live in the human gut without causing health problems.

No competition

“Start Quote

Understanding how this mechanism deactivates toxins provides a basis for developing new therapies that can target toxins directly”

End Quote Dr Jonathan Stamler Case Western Reserve University

A course of antibiotics, which wipes out other bacteria in the gut, can allow C. difficile to multiply and run rampant in the bowels.

They produce large numbers of toxins which enter the cells lining the bowel. This damages the cells resulting in inflammation, cramps, fever, diarrhoea and blood-stained stools.

It is particularly a problem in hospitals as the bacteria can spread, and many patients could be taking antibiotics or have a weakened immune system.

In hospitals in England there were 10,414 C. difficile infections during the financial year 2010-11, down from 33,442 in 2007-08.

Access denied

The whole toxin is unable to penetrate cells so it needs to cleave off a smaller chunk.

Scientists have identified the chemical GSNO - S-nitrosoglutathione - which is produced by the bowels in response to inflammation. It can bind to the toxin, preventing cleavage, so the toxin cannot enter cells.

One of the researchers Dr Jonathan Stamler, from the Case Western Reserve University, said: "Understanding how this mechanism deactivates toxins provides a basis for developing new therapies that can target toxins directly and thereby keep bacterial infections, like C. diff, from spreading."

In experiments on mice, the study showed giving the chemical orally increased survival. Researchers now want to begin clinical trials.

The report's lead author Prof Tor Savidge, from the University of Texas, believes the technique could be used on other infections.

"Along with its potential to provide a much-needed new approach to treating Clostridium difficile infection, the discovery could be applied to developing new treatments for other forms of diarrhoea, as well as non-diarrheal diseases caused by bacteria," he said.

Prof Nigel Minton, from the Clostridia Research Group at the University of Nottingham, said: "This is an exciting discovery.

"Anything that can add to our scant arsenal of available treatments for combating this devastating disease is an important step forward.

"Having said that, one imagines that an actual therapeutic based on this discovery is some way off, either from being developed, and more importantly, from entering the clinic."

More on This Story

Related Stories

• Q&A: Clostridium difficile 19 OCTOBER 2007, HEALTH
• C. diff rise due to 'gene switch' 28 SEPTEMBER 2009, HEALTH
• C. diff testing 'is often wrong' 01 NOVEMBER 2008, HEALTH

Related Internet links

• Nature Medicine
• Case Western Reserve University
• The University of Texas at Austin
• The University of Nottingham

Around the BBC

• BBC Health: Infections

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light on autism

New support for autistic people falling victim to crime

The card provides details for a personal contact police and care staff can approach

A new card will be available to people with autism to help them if they fall victim to crime or are involved in an accident.

The Autism Alert card carries contact details for a person who can help police, firefighters and medical and council staff give the best support.
The National Autistic Society (NAS) Scotland has urged teenagers and adults with autism to apply for it.
Northern Constabulary is among public bodies welcoming the card.
NAS Scotland director Dr Robert Moffat said it was vital that emergency and care services had the right information to support people with autism.
He said: "Being a victim of a crime or accident can be a stressful experience for anyone.
"But for someone with autism, it can be particularly disorientating and frightening."
Dr Moffat added: "People with autism often have difficulty understanding facial expressions, can be very literal in their understanding of questions and easily misinterpret others' intentions.
"In an environment of serious crime or medical emergency these types of misunderstandings can have serious consequences."
Highland Council, Highlands and Islands Fire and Rescue Service and NHS Highland have also offered their support to the initiative.

More on This Story

Related Internet links

• HIFRS
• Highland Council
• National Autistic Society Scotland
• NHS Highland
• Northern Constabulary Policing the Communities of the Highlands and Islands

Around the BBC

• Autism and Asperger syndrome

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Single-sex wards in the NHS 'now the norm'

Eliminating mixed-sex wards has been a long-held goal

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• NHS given mixed-sex wards fines
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Further falls in the number of patients kept on mixed-sex wards has prompted ministers to suggest single-sex accommodation is now the norm in the NHS in England.

In July there were 1,126 breaches - a drop of 90% since December 2010.

More than two thirds of hospitals reported zero breaches with the north east becoming the first region to report no breaches at all.

Ministers said the NHS had done a "fantastic job".

A new system of fines was introduced in April in an attempt to eradicate what has been a long-running problem for the NHS.

Single-sex accommodation means patients share sleeping, bathroom and toilet facilities only with people of the same sex.

Hospitals have to pay £250 for each day a patient is kept in mixed-sex accommodation. Previously, the levels of fines varied considerably depending on the treatment and were inconsistently levied.

'Getting to grips'

The government's drive on mixed-sex accommodation follows attempts by the previous administration to tackle the issue.

Health Secretary Andrew Lansley said: "The NHS has done a fantastic job getting to grips with this. Single-sex accommodation is what people can now expect."

He added as part of the push all hospital refurbishments and new builds should look to ensure half of their beds are in single en-suite rooms.

The rules do allow wards to be segregated into distinct bays as long as they have separate facilities.

They apply to all trusts from acute hospitals to mental health units. Only intensive care and A&E are excused.

More on This Story

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• NHS given mixed-sex wards fines 19 MAY 2011, HEALTH
• NHS gets mixed-sex ward warning 20 JANUARY 2011, HEALTH
• End to mixed sex 'wards' promised 16 AUGUST 2010, HEALTH
• Call for improved hospital stays 13 MAY 2009, HEALTH
• Frustration over mixed-sex wards 23 JANUARY 2009, HEALTH

Related Internet links

• Department of Health
• The Patients Association

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(H1N1) virus

Putative amino acid determinants of the emergence of the 2009 influenza A (H1N1) virus in the human population

1. Daphna Meroz^a,
2. Sun-Woo Yoon^b,
3. Mariette F. Ducatez^b,
4. Thomas P. Fabrizio^b,
5. Richard J. Webby^b,
6. Tomer Hertz^c,¹, and
7. Nir Ben-Tal^a,¹

+ Author Affiliations

1. ^aDepartment of Biochemistry and Molecular Biology, The George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel-Aviv, Israel 69978;
2. ^bDepartment of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN 38105; and
3. ^cVaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109

1. Edited by Barry Honig, Columbia University Howard Hughes Medical Institute, New York, NY, and approved July 8, 2011 (received for review October 6, 2010)

Abstract

The emergence of the unique H1N1 influenza A virus in 2009 resulted in a pandemic that has spread to over 200 countries. The constellation of molecular factors leading to the emergence of this strain is still unclear. Using a computational approach, we identified molecular determinants that may discriminate the hemagglutinin protein of the 2009 human pandemic H1N1 (pH1N1) strain from that of other H1N1 strains. As expected, positions discriminating the pH1N1 from seasonal human strains were located in or near known H1N1 antigenic sites, thus camouflaging the pH1N1 strain from immune recognition. For example, the alteration S145K (an antigenic position) was found as a characteristic of the pH1N1 strain. We also detected positions in the hemagglutinin protein differentiating classical swine viruses from pH1N1. These positions were mostly located in and around the receptor-binding pocket, possibly influencing binding affinity to the human cell. Such alterations may be liable in part for the virus’s efficient infection and adaptation to humans. For instance, 133_A and 149 were identified as discriminative positions. Significantly, we showed that the substitutions R133_AK and R149K, predicted to be pH1N1 characteristics, each altered virus binding to erythrocytes and conferred virulence to A/swine/NC/18161/02 in mice, reinforcing the computational findings. Our findings provide a structural explanation for the deficient immunity of humans to the pH1N1 strain. Moreover, our analysis points to unique molecular factors that may have facilitated the emergence of this swine variant in humans, in contrast to other swine variants that failed.

Vitamin D mum test 'could protect babies from rickets'

By Adam Brimelow Health Correspondent, BBC News

The weakened bones and bowed legs of a child with rickets

Continue reading the main story

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• Lack of sun causes rickets rise
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The NHS should consider checking pregnant women's vitamin D levels to protect babies from the "Victorian" bone disease rickets, an expert says.

A Journal of Medical Screening article suggests rickets was returning, with many women not getting enough vitamin D, which comes mainly from sunlight.

People with dark skin, and women who cover up for cultural or religious reasons, are at particular risk.

The Department of Health is reviewing the evidence on vitamin D screening.

The editorial was by Dr James Haddow, a US expert in pre-natal screening.

Breastfeeding mothers

His article described cases of seizures, heart failure and rickets in children whose mothers were vitamin D deficient.

Dr Haddow said it was time to look at screening pregnant women with a blood test, focusing initially on those most at risk.

"Any strategy aimed at avoiding symptomatic vitamin D deficiency in offspring would logically include assuring adequacy of maternal vitamin D during pregnancy.

"Attending to this aspect of maternal and child health has added significance for mothers who breastfeed."

A recent study in inner-city Birmingham found that almost one in two Asian women were vitamin D deficient.

Continue reading the main story

“Start Quote

Screening in selected populations is currently the way forward”

End Quote Dr Jonathan Berg City Hospital, Birmingham

The level was one in three in the wider Asian community, one in four in the black population and one in eight among Caucasians.

One of the authors, Dr Jonathan Berg, director of pathology at City Hospital, Birmingham, says some local GPs are already screening pregnant women from the Asian community, although there is no formal protocol.

The trust also offers a vitamin D blood-test for those who are not in at-risk groups, for £20. Dr Berg says a lot of people were having the check.

"Screening in selected populations is currently the way forward, but clearly it is very difficult for the NHS to test everyone. We are seeing a big increase in demand from the 'worried well'."

Free supplements

A consultant paediatrician at Ealing's hospital, Dr Colin Michie, says the increased use of high-factor sun-cream means a lot of women who are not in at-risk groups are also vitamin D deficient.

He says the idea of screening is interesting, but he argues that providing free vitamin D supplements for all pregnant women would be cheaper and easier.

He believes this would lead to healthier babies and would save the NHS money.

A spokesman for the Department of Health in England said: "All pregnant women are advised to take vitamin D supplements.

"Our priority is to ensure health professionals provide consistent advice and implement the current recommendations."

The department has asked the scientific advisory committee to review the evidence on vitamin D requirements for different population groups.

More on This Story

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• Lack of sun causes rickets rise 17 JANUARY 2011, PEOPLE AND PLACES
• 'Rickets make a return' in the UK 04 FEBRUARY 2011, HEALTH
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Related Internet links

• Journal of Medical Screening
• Department of Health Public health, adult social care, and the NHS

Around the BBC

• BBC Health: Rickets

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Trainee doctor changeover 'impacts on patient safety'

The survey looked at the month when trainee doctors take up their posts

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The vast majority of doctors believe patient safety is compromised by the August intake of medical trainees, a survey has suggested.

The latest intake of medical trainee doctors start their training posts in the NHS at the beginning of the month.

The figures come in a study from the Society of Acute Medicine and the Royal College of Physicians of Edinburgh.

It found that 90% of doctors who responded said the changeover had a negative impact on patient safety.

The report authors called for an urgent reform to the system to be examined by the UK and Scottish governments.

On the same day trainees start doctors already in training rotate into other positions.

An estimated 50,000 doctors in the UK change over on the first Wednesday in August.

Continue reading the main story

“Start Quote

August is always a nightmare”

End Quote Survey respondent

The RCPE said evidence in recent years had also suggested that there may be a higher early death rate for patients admitted at this time than at other times.

The survey of just under 750 doctors throughout the UK, published in the journal Clinical Medicine, found:

• 93% believed the August changeover had a negative impact on patient care

• 90% believed the changeover had a negative impact on patient safety

• 58% believed the changeover had a negative impact on doctors' training

The effects of the changeover on care and training were perceived to last for up to one month.

Continue reading the main story

“Start Quote

Consideration must be given to making the changeover in training safer”

End Quote Dr Neil Dewhurst RCPE

Most doctors believed a staggered transition by grade, over a period of over a month, could mitigate the impact. One respondent reported: "August is always a nightmare."

Dr Louella Vaughan, honorary consultant physician in acute medicine, and lead author of the study, said: "The results of this survey add to the emerging evidence base which indicates that the current August changeover system increases a number of risks for patients, including an increased early death rate for patients admitted to hospital at this time."

She called for "urgent reform" to the current system.

Dr Neil Dewhurst, president of the Royal College of Physicians of Edinburgh, added: "Formal evidence in support of our concerns has, however, been limited, but is now increasing and has reached the level where it should not be ignored.

"Other changes to established systems within healthcare have been shown to deliver real improvements for patients and similar consideration must be given to making the changeover in training safer.

"We would urge the Scottish and UK governments to review this matter as a matter of urgency."

More on This Story

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• Doctor banks aim to cut NHS costs 13 FEBRUARY 2011, SCOTLAND POLITICS
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Related Internet links

• The Society for Acute Medicine
• Royal College of Physicians of Edinburgh

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