. .
Marian Pierce

Marian Pierce has worked for Japan's National Public radio, taught yoga in Tokyo, and traveled all over India by bus and train. She has an MFA from the Iowa Writers' Workshop, and often writes stories based on people she has met on her travels. You can read her short story about a favorite neighbor in Tokyo, Mrs. Nakamura, by clicking the "publications" button to the left. Other stories have appeared in GQ, STORY, Scribner's Best of the Fiction Workshops 1997, Confrontation, and Puerto del Sol. For Marian's complete bio, click the Biography button.

 

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Management of Bartholin's Duct Cyst and Gland Abscess
  Management of Bartholin's Duct Cyst and Gland Abscess FOLASHADE OMOLE, M.D., BARBARA J. SIMMONS, M.D., and YOLANDA HACKER, M.D. Morehouse School of Medicine, Atlanta, Georgia Bartholin's duct cysts and gland abscesses are common problems in women of reproductive age. Bartholin's glands are located bilaterally at the posterior introitus and drain through ducts that empty into the vestibule at approximately the 4 o'clock and 8 o'clock positions. These normally pea-sized glands are palpable only if the duct becomes cystic or a gland abscess develops. The differential diagnosis includes cystic and solid lesions of the vulva, such as epidermal inclusion cyst, Skene's duct cyst, hidradenoma papilliferum, and lipoma. The goal of management is to preserve the gland and its function if possible. Office-based procedures include insertion of a Word catheter for a duct cyst or gland abscess, and marsupialization of a cyst; marsupialization should not be used to treat a gland abscess. Broad-spectrum antibiotic therapy is warranted only when cellulitis is present. Excisional biopsy is reserved for use in ruling out adenocarcinoma in menopausal or perimenopausal women with an irregular, nodular Bartholin's gland mass. Family physicians can expect to encounter Bartholin's duct cysts or gland abscesses in their female patients. These common problems often can be resolved with the use of simple office-based procedures such as Word catheter placement for duct cysts or gland abscesses, and marsupialization for duct cysts. Anatomy Bartholin's glands (greater vestibular glands) are homologues of the Cowper's glands (bulbourethral glands) in males.1 At puberty, these glands begin to function, providing moisture for the vestibule. The Bartholin's glands develop from buds in the epithelium of the posterior area of the vestibule. The glands are located bilaterally at the base of the labia minora and drain through 2- to 2.5-cmB-long ducts that empty into the vestibule at about the 4 o'clock and 8 o'clock positions. The glands are usually the size of a pea and rarely exceed 1 cm. They are not palpable except in the presence of disease or infection. Epidemiology Bartholin's gland abscesses are almost three times more common than Bartholin's duct cysts. Bartholin's duct cysts, the most common cystic growths in the vulva occur in the labia majora. Two percent of women develop a Bartholin's duct cyst or gland abscess at some time in life. Abscesses are almost three times more common than cysts. One case-control study found that white and black women were more likely to develop Bartholin's cysts or abscesses than Hispanic women, and that women of high parity were at lowest risk. Gradual involution of the Bartholin's glands can occur by the time a woman reaches 30 years of age. This may account for the more frequent occurrence of Bartholin's duct cysts and gland abscesses during the reproductive years, especially between 20 and 29 years of age. Because a vulvar mass in a postmenopausal woman can be cancer, excisional biopsy may be required. Some investigators have suggested that surgical excision is unnecessary because of the low risk of Bartholin's gland cancer (0.114 cancers per 100,000 woman-years). However, if the diagnosis of cancer is delayed, the prognosis can be poor. Pathology Obstruction of the distal Bartholin's duct may result in the retention of secretions and the formation of a cyst. Obstruction of the distal Bartholin's duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland. A Bartholin's duct cyst does not necessarily have to be present before a gland abscess develops.10 Bartholin's gland abscesses are polymicrobial. Although Neisseria gonorrhoeae is the predominant aerobic isolate, anaerobes are the most common pathogens. Chlamydia trachomatis also may be a causative organism. However, Bartholin's duct cysts and gland abscesses are no longer considered to be exclusively the result of sexually transmitted infections. Vulvovaginal surgery is an uncommon cause of these cysts and abscesses. If a Bartholin's duct cyst remains small and does not become inflamed, it may be asymptomatic. However, the cyst typically presents as a medially protruding mass in the posterior introitus in the region where the duct opens into the vestibule.10 If the cyst becomes infected, an abscess may form in the gland. Induration usually is present around the gland,10 and walking, sitting, or sexual intercourse may result in vulvar pain. Bartholin's duct cysts and gland abscesses must be differentiated from other vulvar masses. Because the Bartholin's glands usually shrink during menopause, a vulvar growth in a postmenopausal woman should be evaluated for malignancy, especially if the mass is irregular, nodular, and persistently indurated. Treatment The treatment of a Bartholin's duct cyst depends on the patient's symptoms. An asymptomatic cyst may require no treatment,2 but symptomatic Bartholin's duct cysts and gland abscesses require drainage. Unless spontaneous rupture occurs, an abscess rarely resolves on its own. Although incision and drainage is a relatively quick and easy procedure that provides almost immediate relief to the patient, this approach should be discouraged because there is a tendency for the cyst or abscess to recur. One investigator reported a 13 percent failure rate for the procedure. Furthermore, incision and drainage may make later Word catheter placement or marsupialization difficult.1,16 Definitive drainage involves Word catheter placement for Bartholin's duct cysts and gland abscesses, and marsupialization for duct cysts. Cystic lesions Bartholin's duct cyst Vestibule Usually unilateral; asymptomatic if remains small Epidermal inclusion cyst Labia majora (usually) Benign, mobile, nontender; caused by trauma or obstruction of pilosebaceous ducts Mucous cyst of the vestibule Labia minora, vestibule, periclitoral area Soft, less than 2 cm in diameter, smooth surface, superficial location; solitary or multiple; usually asymptomatic Hidradenoma papilliferum Between labia majora and labia minora Benign, slow-growing, small nodule (2 mm to 3 cm); arises from apocrine sweat glands Cyst of the canal of Nuck Labia majora, mons pubis Soft, compressible; peritoneum entrapped within round ligament; may mimic inguinal hernia Skene's duct cyst Adjacent to urethral meatus in vestibule Benign, asymptomatic; if large, may cause urethral obstruction and urinary retention Solid lesions Fibroma Labia majora, perineal body, introitus Firm, asymptomatic; may develop pedicle; may undergo myxomatous degeneration; potential for malignancy Lipoma Labia majora, clitoris Benign, slow-growing; sessile or pedunculated Leiomyoma Labia majora Rare; solitary, firm; arises from smooth muscle Acrochordon Labia majora Benign, fleshy, variable size; usually pedunculated but may be sessile; polypoid in appearance Neurofibroma Multicentric Small, fleshy; polypoid in appearance; multiple; associated with von Recklinghausen's disease Angiokeratoma Multicentric Rare, benign; vascular; variable size and shape; single or multiple; associated with and aggravated by pregnancy; associated with Fabry's disease Squamous cell carcinoma Multicentric Related to benign epithelial disease in older women and to human papillomavirus infection in young women WORD CATHETHER A vulvar growth in a postmenopausal woman should be evaluated for malignancy, especially if the mass is irregular, nodular, and persistently indurated. A Word catheter is commonly used to treat Bartholin's duct cysts and gland abscesses.12 The stem of this rubber catheter is 1 inch long and the diameter of a no. 10 French Foley catheter. The small, inflatable balloon tip of the Word catheter can hold about 3 mL of saline (Figure 3). After sterile preparation and the administration of a local anesthetic, the wall of the cyst or abscess is grasped with a small forceps, and a no. 11 blade is used to make a 5-mm (stab) incision into the cyst or abscess. It is important to grasp the cyst wall before the incision is made; otherwise the cyst can collapse, and a false tract may be created. The incision should be within the introitus external to the hymenal ring in the area of the duct orifice. If the incision is too large, the Word catheter will fall out. Sterile gloves Iodine solution Lidocaine (Xylocaine), 1% or 2% solution 30-gauge, 1-inch needle with 5-mL syringe for injecting lidocaine Word catheter Saline solution, 3 mL Luer Lock 3-mL syringe for inflating balloon with saline solution Small forceps for grasping cyst wall No. 11 scalpel Gauze pads, 4 3 4 inch Hemostats to break up loculations After the incision is made, the Word catheter is inserted, and the balloon tip is inflated with 2 to 3 mL of saline solution injected through the hub of the catheter. The inflated balloon allows the catheter to remain within the cavity of the cyst or abscess (Figure 3). The free end of the catheter can be placed in the vagina. To allow epithelialization of the surgically created tract, the Word catheter is left in place for four to six weeks, although epithelialization may occur as soon as three to four weeks. Sitz baths taken two to three times daily may aid patient comfort and healing during the immediate postoperative period. Coitus may be resumed after catheter insertion. Unless there is evidence of cellulitis, antibiotic therapy is unnecessary. If cellulitis is present, cultures may be obtained, but the results rarely change management. Empiric broad-spectrum antibiotic therapy is started before culture results are available. If a Bartholin's cyst or abscess is too deep, Word catheter placement is impractical, and other options must be considered. MARSUPIALIZATION FIGURE 3. Inflated Word catheter. An alternative to Word catheter placement is marsupialization of a Bartholin's cyst. This procedure should not be used when an abscess is present. Marsupialization can be performed in the office or, if the cyst is deeply seated, in an outpatient surgical suite. After sterile preparation and the administration of a local anesthetic, the cyst wall is grasped with two small hemostats. A vertical incision is made in the vestibule over the center of the cyst and outside the hymenal ring.18 The incision should be about 1.5 to 3 cm long, depending on the size of the cyst. After the cyst is vertically excised, the cavity drains spontaneously. The cavity also may be irrigated with saline solution and, if necessary, loculations can be broken up with a hemostat. The cyst wall is then everted and approximated to the edge of the vestibular mucosa with interrupted 2-0 absorbable suture.18 Daily sitz baths should begin on the first postoperative day. Approximately 5 to 15 percent of Bartholin's duct cysts recur after marsupialization. Complications associated with the procedure include dyspareunia, hematoma, and infection.1 EXCISION Although Bartholin's gland abscesses may rupture and drain spontaneously, recurrence is likely, and surgical excision may be necessary. Excision is not an office-based procedure. Cultures for N. gonorrhoeae and C. trachomatis may be obtained. However, Bartholin's gland abscesses tend to be polymicrobial, and empiric broad-spectrum antibiotic therapy should be used. Excision of the Bartholin's gland should be considered in patients who do not respond to conservative attempts to create a drainage tract, but the procedure should be performed when there is no active infection.1,4 If multiple attempts have been made to drain a cyst or an abscess, adhesions may be present, making excision difficult and resulting in postoperative scarring and chronic pain in the area. Some investigators recommend excision of the Bartholin's gland to exclude adenocarcinoma when cysts or abscesses occur in patients more than 40 years of age. Even though adenocarcinoma of the Bartholin's gland is rare, gynecologic oncology referral should be considered for older patients with Bartholin's duct cysts or gland abscesses. FIGURE 4. Marsupialization of Bartholin's duct cyst. A vertical incision is made over the center of the cyst to dissect it free of mucosa. (Right) The cyst wall is everted and approximated to the edge of the vestibular mucosa with interrupted sutures. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. The authors thank Barbara S. Apgar, M.D., M.S., associate editor of AFP, for editorial assistance. REFERENCES Stenchever MA. Comprehensive gynecology. 4th ed. St. Louis: Mosby, 2001:482-6,645-6. Hill DA, Lense JJ. Office management of Bartholin gland cysts and abscesses. Am Fam Physician 1998; 57:1611-6,1619-20. Govan AD, Hodge C, Callander R. Gynaecology illustrated. 3d ed. New York: Churchill Livingstone, 1985:19,195-6. Azzan BB. Bartholin's cyst and abscess. A review of treatment of 53 cases. Br J Clin Pract 1978;32(4): 101-2. Kovar WR, Scott JC Jr. A practical, inexpensive office management of Bartholin's cyst and abscess. Nebr Med J 1983;68:254-5. Kaufman RH. Benign diseases of the vulva and vagina. 4th ed. St Louis: Mosby, 1994:168-248. Aghajanian A, Bernstein L, Grimes DA. Bartholin's duct abscess and cyst: a case-control study. South Med J 1994;87:26-9. Stillman FH, Muto MG. The vulva. In: Ryan KJ, Berkowitz RS, Barbieri RL, eds. Kistner's Gynecology: principles and practice. 6th ed. St. Louis: Mosby, 1995:66-8. Visco AG, Del Priore G. Postmenopausal Bartholin gland enlargement: a hospital-based cancer risk assessment. Obstet Gynecol 1996;87:286-90. Wilkinson EJ, Stone IK. Atlas of vulvar disease. 5th ed. Baltimore: Williams & Wilkins, 1995:11-5. Cheetham DR. Bartholin's cyst: marsupialization or aspiration? Am J Obstet Gynecol 1985;152:569-70. Word B. Office treatment of cyst and abscess of Bartholin's gland duct. South Med J 1968;61:514-8. Brook I. Aerobic and anaerobic microbiology of Bartholin's abscess. Surg Gynecol Obstet 1989; 169:32-4. Saul HM, Grossman MB. The role of Chlamydia trachomatis in Bartholin's gland abscess. Am J Obstet Gynecol 1988;158(3 pt 1):76-7. Peters WA 3d. Bartholinitis after vulvovaginal surgery. Am J Obstet Gynecol 1998;178:1143-4. Apgar BS. Bartholin's cyst/abscess: Word catheter insertion. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care physicians. St. Louis: Mosby, 1994:596-600. Mathews D. Marsupialization in the treatment of Bartholin's cysts and abscesses. J Obstet Gynaecol Br Commonw 1966;73:1010-2. Horowitz IR, Buscema J, Woodruff JD. Surgical conditions of the vulva. In: Rock JA, Thompson JD, eds. Te Linde's Operative gynecology. 8th ed. Philadelphia: Lipincott-Raven, 1997:890-3.


 
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