TRAVELING ABROAD TO JERUSALEM: HOPEFUL NEW BLOOD

TRAVELING ABROAD TO JERUSALEM: HOLY WEEK,
HOPEFUL NEW BLOOD INTO THE LIFE OF TRAVELERS.

OVERVIEW.

Founded around 3000 BC , the old city various name for Jerusalem: Jerusalem, City of David, Zion, Jerushalayim [Hebrew], Al-Quds [Arabic].
The awe-inspiring vistas of the ages amidst all the state-o-the-art facilities and amenities called by modern tourist, make the Jerusalem the ideal destination for travelers.





Picture 1:


Photo shot of Sahalataylor [Me] and my spouse Mrs B.Tampubolon,SH,Lawyer [BT] sat on the top of Mount of Olives with the background the panoramic view of Old City of Jerusalem.


Note the Holy Sepulchre is in the right side and Dome of the Rock in the left side.



Jerusalem is one of the most ancient cities in the world, it is situated 800 meters above sea level in the heart of the Judean Mountains.
Jerusalem is a city venerated by Jews, Christian and Muslim alike.
The Western Wall is the Jewry’s holiest site.
The Holy Sepulchre is the Christian’s holiest site.
The Dome of the Rock and El-Aqsa shrine are the third holiest site for Muslim or Islam after Mecca and Medina.

“ Thus said the Lord God; this is Jerusalem: I have set it in the midst of the nations and countries that are round about her [ Ezekiel 5: 5] “.

Its land area is 652 km squares [including East Jerusalem, administered by Israel since 1967].
Population at times of Jesus: 80 000 [Time Magazine].
Its population of 889 300 [2008] includes 67.9 % Jews, 28.3 % Muslims, 1.8 % Christians, 2 % unclassified by religion.
The Mount of Olives and the Old City of Jerusalem are two sites have sanctuaries for Christians, Jews and Islam.
Have a nice travel ! Welcome the celebration of the Easter !
The Goal of Human Life is not long life and death, but Resurrection and Forever Life.



Contents:

I. Overview
II Tips for traveling abroad.
III. Mount of Olives.
IV The Old City of Jerusalem.
V. Christian’s Sanctuaries in Mount of Olives.
1. Pater Noster Church or Lord’s Prayer Church
2. Dominus Flevit
3. Church of All Nations, Basilica of the Agony
4. Gethsemane Garden
5. Mary Magdalene Church
6. The Church of the Assumption
7. The Tomb of Virgin Mary

VI Christian’s Sanctuaries in Old City and nearby the Wall.

1. Basilica Dormiton
2. The Hall of the Last Supper
3.The Hall of the Washing feet 4. St. Peter Gallicantu
5 Via Dolorosa [Way of the Grief or Way of Suffering]
6 Ecce Homo or “Behold the man ! ”
7 Church of Holy Sepulchre or Church of the Resurrection
8 Garden Tomb

VII Jew’s Sanctuaries in Jerusalem
1 Western Wall
2 Temple Mount
3 Mount of Moriah
4 The Tomb of King David

VIII Muslim or Islam Sanctuaries in Jerusalem
1 Dome of the Rock
2 EL Aqsa

IX The Holy Week in Latin Catholic Rome
1 Palm Sunday [Passion Sunday]
2 Holy Monday to Wednesday
3 Holy Thursday
4 Good Friday
5 Holy Saturday
6 Easter Vigil
7 Easter Sunday

X Holy Week in Protestant Churches

XI The Ascension of Jesus

XII References.


II. TIPS FOR TRAVELING ABROAD.

Here are some quick tips to make your travel easier and safer:
• Register so the State Department can better assist you in emergency.
• Sign passport, and fill in the emergency information page of your passport.
• Leave-copies of itinerary, and passport data page and visas with family or friends.
• Check your overseas medical insurance coverage.
• Familiarize yourself with local conditions and laws.
• Take precautions to avoid being a target of crime; do not wear conspicuous clothing or jewelry and do not carry excessive amount of money. Also do not leave unattended luggage in public areas and do not accept packages from strangers.
• Contact State Department in an Emergency.
Source: http://travel.state.gov/travel/tips/...
There are some conditions to realize traveling abroad to Jerusalem such as: Availability of funds or money, good health, spare time, friends, opportunity and spiritual readiness.
The impact of traveling : Hopeful we have New Blood is brought into the life of the travelers. Have a nice travel. Welcome the celebration of Easter.
The Goals of human life is not long life and death, but Resurrection and Forever Life.

BREAST CANCER RADIATION,CHEMO AND HORMONAL THERAPY.

RADIATION.CHEMO AND HORMONAL THERAPY

RADIATION THERAPY OF BREAST CANCER.

Many women have treatment in addition to surgery, which may include radiation therapy, chemotherapy and hormonal therapy.
Radiation is a local treatment and therefore works only on the cancer cells that directly in its beam. Radiation therapy directs high energy rays at the breast area, under the arm, and/ or the collar bone area to destroy an invasive carcinoma cells that may be left behind surgery. This treatment also reduces the risk of recurrence [the cancer coming back].

The ways of giving radiation therapy as follows:
• External beam radiation: The treatments are directed to the entire breast after surgery to the area of skin, muscle and lymph nodes. Radiation therapy is usually given 5 days a week over 5 to 6 weeks. Each treatment takes only a few minutes.
• Internal partial-breast irradiation, also called brachy-therapy, is a form of treatment in which radioactive materials such as seeds or pellets are temporarily placed in or near the cancer was removed.
• External partial-breast irradiation is a method of external beam radiation that zeroes in the area around where the cancer was. This area is at risk of recurrence. Partial-breast radiation takes only 5 to 10 days for treatment versus 5 to 7 weeks for whole breast radiation.
Radiation therapy is painless and has relatively few side effects. However, it can irritate the skin or causes a burn similar to a bad sunburn in the area of radiation.

CHEMOTHERAPY OF BREAST CANCER.

Chemotherapy consists of the administration of medications that kill cancer cells or stop them from growing. There are 3 methods of chemotherapy:
• Adjuvant chemotherapy [CT] where the CT is given after surgery. It is given to reduce the possibility of recurrence [return of cancer]. Women with node-positive disease have a high risk of both local and systemic recurrence. Thus , lymph node status directly indicates the risk of occult [hidden] distant micro-metastasis.

Fig. 24: The log-kill hypothesis graph.

Patients with widespread cancer may have up to 10 power 12 tumor cells throughout the body at the time of diagnosis.

Relationship of tumor cell number to time of diagnosis, symptoms, treatment and survival.Three alternative approaches to drug treatment are shown for comparison with the course of tumor growth when no treatment is given [dashed line]

1. In the protocol diagrammed at top, treatment [indicated by the arrow] is given infrequently and the result is manifested as prolongation of survival but with recurrence of symptoms between courses of treatment and eventual death of the patient.

2. The combination chemotherapy treatment diagrammed in the middle section is begun earlier and is more intensive. Tumor cell kill exceeds regrowth, drug resistance does not develop, and "cure" results. In this example treatment has been continued long after all clinical evidence of Cancer has disappeared [1-3 years]. this approach has been established as effective in the treatment of childhood acute leukemia, testicular cancers, and Hodgkin's disease.

3. In the treatment diagrammed near the bottom of the graph, early surgery has been employed to remove the primary tumor and intensive adjuvant chemotherapy has been administered long enough [up to one year] to eradicate the remaining tumor cells that comprise the occult micrometastases.

In this situation, postoperative use of systemic adjuvant CT protocol”
Six cycle of cyclophosphamide, metrotrexate, and fluorouracil [CMF protocol] or
Fluorouracil, doxorubicin, and cyclophosphamide [FAC] has been shown to
significantly reduce relapse rate and prolong survival.
Each of these CT regimes has benefited women with stage 2 breast cancer with
one to three involved lymph nodes.
• Neo-adjuvant CT where CT may be given before surgery to shrink the cancer.
• Palliative CT. The approach to women with advanced breast cancer or stage 4 remains a major problem, as current treatment options are only palliative [to improve symptoms and help live longer, not cure the cancer]. Combination of CT and hormonal therapy has been found to reduce higher and more durable remissions of patients.

HORMONAL THERAPY OF BREAST CANCER.

If the cancer tested positive for hormone receptors, the patient’s doctor will recommend some form of hormone therapy. Hormonal therapy also called anti-estrogen therapy, works by lowering the amount of estrogen in the body or blocking the estrogen from signaling breast cancer to grow.
• The anti-estrogen Tamoxifen has proved to be useful for the treatment of both early stage and metastatic breast cancer. It is also approve as a chemotherapy agent in women at high risk for breast cancer. Tamoxifen usual adult dose is 20 mg/day orally. Tamoxifen is given orally and is rapidly and completely absorbed. Tamoxifen is well tolerated, and its side effects are generally mild
• Aromatase inhibitors. Aminoglutethymide is primary used in the treatment of metastatic breast cancer in women whose tumors express significant levels of estrogen or progesterone receptors. It also has activity in hormone dependent advanced prostate cancer.Aminoglutethimide is normally administered with hydrocortisone to prevent symptoms of adrenal insufficiency. Usual adult dosage: 250 mg orally twice daily and hydrocortisone 20 mg twice daily. Adverse effects are fatigue and mild nausea..

Anastrozole [Arimides] is a selective non-steroidal inhibitor of aromatase that has no inhibitory effect on adrenalglucocorticoid. It is presently approved for first line treatment of post-menopausal women with metastatic breast cancer, and as adjuvant therapy of postmenopausal women with hormone-positive, early stage breast cancer. Usual adult dosage:

1 mg orally daily. Adverse effects are mild nausea and headache.

HERZ-TARGETED THERAPY.

Herceptin [Trastuzumab] is a recombinant DNA-derived, humanized monoclonal antibody that binds to the extra cellular domain of the human epidermal growth factor receptor HER-2/neu. This antibody blocks the natural ligand from binding and down-regulate the receptor. Transtuzumab is approved for he treatment of metastasis breast cancer in patients whose tumors over-express HER-2/neu. Herceptin usual dosage: 440 mg powder; reconstitute for intravenous [IV] infusion.

BREAST RECONSTRUCTION

RECONSTRUCTION OF BREAST.

For aesthetic considerations, as well as to correct defects from extended removal of the breast for malignancy, reconstruction or repair is used. This includes the option:
• Derma-fat-fascia graft reconstruction for replacing breasts contour.
• Trans-rectus [longitudinal] abdominal muscle [TRAM] Flap breast reconstruction.
• Breast Implants
• Breast Prostheses.

DERMA-FAT-FASCIA GRAFT RECONSTRUCTION.

This method includes:
• Skin grafting
• Various flap operations
• A number of more extended plastic procedures.
This method describes an abdominal plastic operation based on transposing flaps from the upper abdomen to the defect on the chest.
The doctor has found that a fat graft, covered by a layer of derma on one side and with fascia as its base, will attach itself more firmly to the recipient base. Since this type of graft is easily invaded by capillaries, there is an increase in the vitality of the fat tissue and a tendency to regenerate very satisfactorily.

Fig. 17:

Coronal section of the breast before and after implantation of derma-fat-fascial graft.

This method greatly reduces the amount of absorption of the fat and renders the graft more resistant to infection and may completely healed.
Fat grafts without the attachment of the derma and fascia absorb at least from one-third to one-half of their volume.This method is more satisfactory than the pedicle clap method of rebuilding the contour of the breast; it eliminates extra stages of operation and unnecessary scarring; moreover, the resulting contour is more pleasing. Berson emphasizes the precaution that, before the reconstruction is undertaken, the area to be operated on must be free from any infection and completely healed.

Fig. 18:

Derma-fat-fascial graft for replacing breast contours.

TRAM FLAP BREAST RECONSTRUCTION .

TRAM [Trans-rectus [longitudinal] abdominal muscle], which is located in the lower abdomen between the waist and the pubic bone.
TRAM flap reconstruction is the most popular of all reconstruction options, especially for a woman with excess belly fat or an abdomen that has been stretched out by pregnancy.
You end up with a “tummy tuck“ as a fringe benefit of surgery.


Figure 19: TRAM Flap breast reconstruction preparation.

Woman after mastectomy, showing trans-rectus abdominal muscle [TRAM] and surrounding tissues in preparation for reconstruction.

A Mastectomy site

B Right trans rectus abdominal muscle

C Left trans rectus abdominal muscle

D Segment of abdominal tissues: skin and fat, to be transferred along with muscle to create the new breast

Figure 20: TRAM Flap breast reconstruction-process.

Woman in process of trans-rectus abdominal muscle tram]

Reconstruction:

A Lines of reconstructed breast incisions

B Right-trans rectus abdominal muscle

C Left TRAM muscle is swung over to recreate the new

breast

D Incision circle of repositioned "belly button" incision

E Line of abdominal surgery.

How does Tram work ?
An oval section of skin , fat and muscle is taken from the lower half of the abdomen and slid up though a tunnel under the skin to the breast area. Blood vessels remain attached whenever is possible. The tissue is shaped into a natural looking breast and sewn into place.
If blood vessels have been cut, the surgeon reattaches them to blood vessels in the chest area using a microscope to sew the tiny, delicate attachments. The procedure takes about 3 hours. The new breast can also be made during this surgery, with an implant underneath your own tissue.

Figure 21: Tram Flap breast reconstruction-lines of incision. Woman with lines of trans-rectus abdominal muscle [TRAM] reconstruction incisions.

A Line of reconstructed breast incisions

B Circle of re-positioned "belly button" incision

C Line of abdominal surgery incision.

The TRAM is not a good choice for:
• Thin women who don’t have enough abdominal tissue
• W0men who smoke and therefore have blood vessels that are narrow and less flexible.
• Women who have multiple surgical scars on the abdomen.

BREAST IMPLANTS.

Breast Implants involve the least amount of surgery of all your reconstruction options. Slim, small-breast women tend to do best with breast implants, because they often don’t have enough excess belly tissue to form a good tissue transplant. Also, it’s easy to achieve a smaller breast size with implants.

Fig. 22: Breast implant

Filled tissue expander, side view of breast area with filled tissue expander in place.

A Tissue expander-filled

B Port

C Catheter

D Syringe

E Ribs

F Pectoral major muscle

G Other muscles of the chest wall [3 lines to one letter]

Breast implants only come in three sizes [small, medium and large] and the largest is a size 12-14.
For most women, the skin that remains after mastectomy must be stretched or expanded to make room for an implant. To stretch the skin, the surgeon inserts a balloon-type device called a tissue expander under the chest muscle. The expander has a port [a metal or plastic plug, valve, or coil].The port allows the surgeon to add increasing amounts of liquid over time [about six months], without extra surgery.
Gradually, your skin and soft tissue are stretched to achieve your desired appearance.
The final steps, when stretching is done and you’re your other treatments [chemotherapy, radiation or both] are completed, the expander is usually replaced with a permanent implant. Breast implants are filled with either saline [saltwater] or silicone gel.

BREAST PROSTHESES.

Breast prostheses come in many shapes, sizes and materials: silicon gel, foam, or fiberfill interior, weighted or not. The ideal product will have the shape, weight, balance, motion and simulated nipple of a real breast.
You can choose among ready-made products to match your remaining breast or your former shape. There’s even a breast prostheses that comes with adhesive patches that attach to the upper edge of your breast area, allowing you to go bra-less if you like.

Fig. 23: Breast prostheses

MASTECTOMY STEP 6, 7 AND AFTER SURGERY.

MASTECTOMY STEP 6 , 7 AND AFTER SURGERY.

• Step 6: Ligate or tie and divide all tributary vessels in this locality: this is to go hand to hand with the removal of all fat, lymph nodes and other elements, Fig 15 .

Fig. 15:

A moist gauze is packed in the axilla [armpit] after it is cleaned. The sternocostal attachments of pectoral muscles are divided next. The perforating branches of the interior mammary artery tied with transfixing sutures. Fibers of the serratus anterior muscle should not be disturbed.

1, Serratus anterior muscle; 2, pectoral major and minor muscles; 3, intercostal muscles.

• Step 7: Close the wound. Introduce a rubber or cigarette drain through a stab wound. Hemostasis [control of bleeding] must be perfect. The skin should be closed with interrupted sutures. Fig 16

Fig. 16:

A. Dissection is completed. Note that portion of anterior rectus sheath is also removed;

1, Axillary vein; 2, cephalic vein; 3, thoraco-dorsal nerve; 4, long thoracic nerve; 5, external abdominal oblique muscle; 6, rectus abdominal muscle.

B. Wound closed. Note position of drain, which passes through the lateral flap in region of axilla. A compression dressing completes the procedure.

After surgery.
If everything being satisfactory, the patient is permitted to leave the bed after 24 or 48 hours and to use her arm. Dress the wound and remove the drainage tube after 48 hours. Sutures should be removed gradually over a 12-day period.

MASTECTOMY, STEP 5 SURGERY .

MASTECTOMY, STEP 5 SURGERY

• Step 5: Cleaning out the armpit. Expose the armpit vein. The armpit vein usually is a large single trunk but often is found as two branches.








The nerves of the brachial plexus surround the armpit vein. A number of tributary veins enter it from the armpit fat; the largest and most important of these is the scapular vein which accompanies the scapular artery; Fig. 14.











Fig. 14:



A Both pectoral muscles are strongly retracted inferiorly. The fascia overlying the axillary vein is removed, care being taken not to injure this vessel. The axillary fat is exposed:



1, Deltoid muslle; 2, cut edge of pectoral minor tendon; 3, axillary vein; 4, cut edge of pectoral major tendon; 5, pectoral major muscle; 6, pectoral minor muscle; 7, axillary fat pad; 8, coracobrachialis muscle; 9, cut edge of pectoral major muscle; 10, short head of biceps muscle.







B The axilla is cleaned by blunt dissection. Note the cords of brachial plexus and the axillary artery:



1, Cords of brachial plexus; 2, cephalic vein; 3, axillary vein; 4, axillary artery; 5, short thoracic vessels; 6, serratus anterior muscle; 7, long thoracic nerve; 8, pectoral minor muscle; 9, pectoral major muscle; 10, axillary fat pad with lymphatics; 11, thoracodorsal nerve, 12, latissimus dorsi muscle.

RADICAL MASTECTOMY, STEP 3 and 4

RADICAL MASTECTOMY, STEP 3 and 4.

· Step 3: Dissection of the greater pectoral muscle almost as far as its humoral [upper arm] attachment. The entire mass [pectoral major muscle and mammary gland] is dissected away from the ribs. Fig. 13: A,B.




Fig 13:





A The cephalic vein is dissected free. Humeral [upper arm]

end of pectoral major is retracted downward.

1, Deltoid muscle; 2, cephalic vein; 3, pectoral major

muscle




B The clavicular origin of pectoral major is divided. The thoracic-acromial vessels are ligated: 1, coracoid process; 2, thoracic-acromial vessels; 3, costo-coracoid membrane; 4, pec toral minor.



C The costocoracoid membrane is open.The pectoral major is retracted down still more, exposing pectoral minor, which is divided along its attachment to the coracoid process:

1, Deltoid muscle; 2, coracoid process; 3, cephalic vein; 4, axillary vein; 5, thoracic-acromial vessels; 6, edge of costocoracoid membrane; 7, pectoral major muscle, 8, pectoral minor muscle.





· Step 4: Expose the outer edge of the pectoral minor in it’s entirely. The gland and major pectoral muscle now are attached only by connective tissue and armpit fat. Fig. 13: C.

[cont.]

OPERATIONAL PROCEDURES OF MASTECTOMY

OPERATIONAL PROCEDURES OF MASTECTOMY.

What is happened to the patients breast in mastectomy surgery ?
The skin incisions shown in Figure 12 will suffice for all intents and purposes; it can be extended and amplified to meet the special needs of a given case. Ample exposure and through anatomic dissections are essentials. The axilla [armpit] should be dissected first. This procedure is about radical mastectomy, another types of mastectomy are less advance than the radical mastectomy, they are the modification of the radical mastectomy according to the stage of the breast cancer.

• Step 1: The skin along the entire margin of the incision is freely dissected up from the under lying tissue to an extent shown in Fig 12
• Step 2: Expose the pectoral fascia in the line of the upper incision. Lift the skin and fat off the muscle until the furrow is reached; this furrow marks the dividing line of pectoral major muscle.

Fig.: 12 The skin incision for step 1 of radical mastectomy following by step 2 to expose the pectoral fascia in the line of the upper incision.

A.Shows skin incision.

B Humeral [upper arm] head of pectoral mayor is divided.

[Note cephalic vein in delto-pectoral groove].

1. Deltoid muscle; 2, cephalic vein; 3,pectoral major

muscle; 4, tumor or cancer. [cont.]