42.6 F
New York
Friday, March 29, 2024
Home Blog Page 2135

What is a Hernia? – A Laparoscopic Surgeon Tells All

0
An anatomical representation of the lower abdominal wall, demonstrating the muscular layers, as well as the orifices and tubes that normally travel thru them.

By: Dr. Anthony Vine

What is a Hernia? As a Laparoscopic General Surgeon, I am able to care for complex intestinal problems— diverticulitis, colon cancer, Crohn’s disease, gastroesophageal reflux (GERD)—with a television camera and tiny scars, but perhaps one of the most common patient issues that faces me every day is a hernia. What is a hernia? Do all hernias need to be fixed? Can and should hernias be repaired laparoscopically? What is mesh made of, and is it safe to deploy in the human body? These are just a few of the questions that as doctors, we must explain to our patients.

A loop of small bowel traversing downward thru the inguinal canal, ie, an inguinal hernia.

Because we could write volumes on the topic of hernias, I will limit todayʼs discussion to the definition and development of a hernia, and leave the issues of surgical treatment to a subsequent article. At this point, before I answer any of the above questions, I should digress and elucidate for you the origins of the words “doctor” and “patient.”

I must confess that my route to becoming a surgeon was via several years of ancient Greek and Latin studies at Phillips Academy and as an English Literature major at Princeton University, prior to attending Vanderbilt University School of Medicine. Subsequently, I trained at Mount Sinai Hospital, NY in General Surgery and attended the Massachusetts General Hospital for a research fellowship in cardiovascular surgery. I was not your usual biochemistry major: rather, I took a more humanistic approach to the practice of medicine and surgery. Linguistically speaking, the two words are derived closely from Latin.

The first, “doctor,” is from “doceo, docere, doctus,” meaning “to teach,” while the latter stems from the verb “pateo, patere, passus (sum)”—“to suffer.” So, in essence, a doctor is one who teaches, and a patient is one who suffers. Now that we have our definitions, I can teach you, as I would to a patient sitting across the desk from me in my office, what a hernia is and why someone may be suffering from this ailment.

Simply stated, a hernia is a hole or weakness in the musculature of the abdomen, allowing either fat or an organ to protrude, to travel from inside one space to another space. I will even go so far as to say that many hernias are really just normally occurring holes that Hashem created in our bodies, but that the holes have become too wide or too large, and are now allowing other entities to process through such an enlarged orifice.

Why did Hashem make these holes in our body? Was it a mistake or an error, an oversight during creation? Hardly. These holes allow conduits or tubes (remember, a surgeon is merely a plumber of sorts)—arteries, veins, bowels, nerves—to traverse from one part of the body to another. For example, if we did not have a hole in our diaphragm muscle, then the esophagus would never connect to the stomach, and we would be unable to eat by swallowing our food. If the hole through which the esophagus travels becomes wide over time, then the stomach can migrate up above the diaphragm into the chest, causing, in many cases, food regurgitation, heartburn (acid reflux), chest pain, bad breath, and many other symptoms.

A picture of some of the basic types of hernias that are mentioned in the latter section of the article.

So, what is an inguinal hernia? When we are in the womb, men and women undergo development of their respective gonads. In a male, the testicle is originally part of the lower aspect of the kidney: it breaks away, takes along with it its artery and veins, and on the way, joins up with the vas deferens (aka, the spermatic cord). This complex then pushes its way through the abdominal muscle in the groin (“inguinal” canal), and takes every layer of the abdominal wall along with it to create the protective housing called the scrotum (if you look at the scrotum under a microscope, it has the same six layers of the abdominal wall).

Now, if the abdominal wall at around the time of birth does not close snugly or completely around the testicle triad of tubes, there may be a gap alongside these structures, and there we have the origin of what we call an inguinal hernia. Over one’s lifetime—even in the early months of life—intraabdominal organs (bowels, aka “kishkes,” the bladder, the appendix, etc) may protrude through this canal and cause a bulge or swelling in the groin or scrotum, either with or without symptoms, ranging from discomfort or pain, to constipation, to even bladder issues.

Women are not immune from developing groin hernias, too, since the suspensory ligaments of the uterus (the “round ligament,” as it is called) carry the similar developmental openings in the groin area of the abdominal wall. We even see hernias in the upper thigh, called femoral hernias (this varietal fun more common in women), which travel in the space under the groin (“inguinal”) ligament medially to the iliofemoral “groin” blood vessels. Remember that if there were no window in the muscle in this region for those blood vessels, we would never be able to get blood from the abdominal aorta all the way to the legs, feet and toes!

There are many other such hernias—epigastric, lumbar, obturator, Spigelian, just to name a few—as well as the other very common one, called an “umbilical hernia,” a result of the weak abdominal tissue where we were attached until birth to our mothers. Many individuals present with multiple hernias—weak tissue in several different areas, and there are some who develop, or acquire, hernias more acutely—such as a diaphragmatic hernia from trauma, as in a car accident or a very bad fall. Muscles can rupture from trauma and cause protrusions. People who have had prior abdominal surgery may end up with a breakdown of the abdominal closure, even many years later: we call these incisional hernias, whether they be from an old appendix scar, an open colon or stomach surgery, or even a laparoscopic incision.

Dr. Anthony Vine

A bulge in the musculature of the upper abdominal wall that many people have when they do a sit-up may not even be a hernia at all, but rather a “rectus diastasis,” from the Greco-Latin roots, “dia-apart” and “sto-to stand”: in other words, the two abs (“six pack” muscles) are separated in the middle by a weak central tendon. Plastic surgeons may fix this, called a “tummy tuck,” but it is not a “hernia” per se—just an unsightly and perhaps demoralizing body habitus. As hernias go, most bulges without any symptoms are not surgical emergencies: however, a painful or even red lump or bulge on the abdominal wall that does not recede or get better when you are supine (lie down) should make you seek medical attention, as this may represent a hernia that is stuck (“incarcerated”) or contains choked tissue (“stangulated”): a true surgical emergency. Indeed, albeit a long lesson on hernias, we have scratched only the surface.

In the next installment, we will consider the other questions posed above: the science behind the methods of hernia repairs; the use and safety of mesh; and the expected outcomes, including postoperative care. Wishing a Shana Tovah and good health to all.

Dr. Anthony Vine is a laparoscopic surgeon in NYC. He attended Phillips Academy, Princeton University and Vanderbilt Medical School, with surgical residencies at Mount Sinai Hospital (NYC) and Massachusetts General Hospital (Boston). His expertise includes: GERD and other esophageal diseases (achalasia, cancer), hernia surgery, colon surgery (cancer, diverticulitis) and inflammatory bowel disease (Crohn’s, ulcerative colitis). In addition to being one of New York Magazine’s “Best Doctors” and a long-standing Castle Connolly “Top Doctor,” he continues to play violin both professionally and as an amateur, having performed at the Verbier Festival (Switzerland) and with the Roosevelt Island concert series

            (NYC, RRconcerts.org).

Report: Anti-Semitic Harassment at U.S. College Campuses Hits Historic Levels

0
Anti-Semitic harassment on college campuses aimed at pro-Israel students jumped by 70 percent in the past year, the highest levels ever seen, according to a new study showing that the endorsement of anti-Israel causes by students and professors has created an unsafe environment for Jewish students. Photo Credit: jewhatredoncampus.org

‘Israel-related anti-Semitic harassment increased 70 percent’

By: Adam Kredo

Anti-Semitic harassment on college campuses aimed at pro-Israel students jumped by 70 percent in the past year, the highest levels ever seen, according to a new study showing that the endorsement of anti-Israel causes by students and professors has created an unsafe environment for Jewish students.

Anti-Semitic expression and acts on campus continue to rise to historic levels, according to the study. Israel-related anti-Semitic expression increased significantly in amount and blatant eliminationist intent, the report found.

Harassment of students who expressed pro-Israel ideologies jumped 70 percent from 2017 to 2018, according to a new report by the AMCHA Initiative, a campus organization that monitors anti-Semitism on more than 400 college campuses and that has recorded some 2,500 anti-Semitic incidents across the U.S. since 2015.

AMCHA found in its latest report that while examples of classical anti-Semitism decreased overall, there has been a major spike in students being targeted for hate speech and violence due to their open support for the state of Israel.

The findings jibe with anecdotal evidence seen across the country of Jewish and pro-Israel students experiencing violence and harassment from those associated with the anti-Semitic Boycott, Divestment, and Sanctions movement, or BDS, which aims to wage economic warfare on Israel. The BDS movement has put major resources into its campus activities and it appears to be bearing fruit across the United States.

Hostility toward Israel’s supporters on campus “reached near-historic levels” during the past year, according to the report.

“Antisemitic acts involving the singling out of Jewish and pro-Israel students and groups for personal vilification more than doubled,” including a 147 percent increase in incidents of the students being linked to “white supremacy,” according to the findings. “Attempts to exclude” Jewish and pro-Israel students “from campus activities more than doubled, with expression calling for the total boycott or exclusion of pro-Israel students from campus life nearly tripling.”

The findings are a sign that hatred toward Jews and pro-Israel students is primarily coming from activists aligned with the BDS movement, rather than classic anti-Semitic motivators such as white supremacist ideologies.

“While acts of classical antisemitism in the U.S. reached near-historic levels in 2018 and included the deadliest attack against Jews in American history, the nation’s colleges and universities revealed a somewhat different but nonetheless troubling story,” according to AMCHA’s study. “On campuses across the country, harassment motivated by classical antisemitism actually decreased, and significantly so. At the same time, however, the number of Israel-related acts of harassment increased significantly.”

Anti-Semitic expression and acts on campus continue to rise to historic levels, according to the study.

Israel-related anti-Semitic expression increased significantly in amount and blatant eliminationist intent, the report found.

“Expression demonizing and delegitimizing Israel,” for example, “increased by 32%, with expression accusing Israel or Zionism of ‘white supremacy’ more than doubling,” according to the report.

“Expression promoting or condoning terrorism against Israel increased by 67%” during the past year.

Researchers also discovered a “dramatic increase in student and faculty acknowledgment of anti-Zionist intent,” as both student and faculty supporters of the BDS movement become more emboldened in their advocacy.

Words and acts “promoting or condoning the elimination of Israel more than doubled,” according to the study. It also found a “three-fold increase from 2017 to 2018 of incidents involving individuals or groups openly acknowledging their opposition to Zionism.”

Moreover, “expression by BDS supporters acknowledging that the goal of BDS is to bring about or facilitate the elimination of Israel” increased from one incident in 2017 to 32 in 2018.

Much of this rise has been attributed to the willingness of college faculty members to lend their voices to the BDS and anti-Israel movement.

This includes academic boycott of Israel, which was linked to 86 percent of the anti-Semitic harassment, and a dramatic increase in faculty members promoting BDS and anti-Israel activism.

“Academic BDS is primarily a faculty-driven boycott, whose rise in prominence and popularity on campuses across the country is linked to the increased participation of faculty in the anti-Zionist rhetoric and behavior associated with it,” according to AMCHA.

“Events sponsored by academic departments that contained the demonization or delegitimization of Israel increased by 85%,” the study found.

“Taken together, these results suggest that the significant increase in acts of Israel-related harassment seen in 2018 may have been a direct consequence of the increased promotion and implementation of academic BDS,” according to the researchers.

Tammi Rossman-Benjamin, AMCHA’s director and a member of the research team, said that it is becoming clear that college faculty members are now directly contributing to the rise of anti-Semitism on campus.

“Academic BDS is more dangerous than people realize,” Rossman-Benjamin said in a statement. “Not only does implementation curtail students’ educational rights and opportunities, its promotion on campus, particularly by faculty who give it academic legitimacy, is inciting an alarming increase in harassment against Israel’s presumed supporters, first and foremost Jewish students. Administrators must take the necessary steps now to stop these unacceptable acts of intolerance.”

            (Washington Free Beacon)

Understanding the “Aseret Yemai Teshuvah”–Ten Days of Repentance

0
Immersing ourselves in heartfelt prayer and acts of kindness during the 10 days of repentance between Rosh HaShana and Yom Kippur can tip the balance of the scales in our favor

Edited by: JV Staff

(Some of what follows is based on these works: “The Festivals in Halachah,” by Rabbi Shlomo Yosef Zevin, ZT”L, translated by Rabbi Shlomo Fox-Ashrei, and published in 1981 by Mesorah Publications (NY) and Hillel Publications (Jerusalem) and on the work “Aspaklarya,” by Rabbi Shmuel Avraham Adler, published by Aspaklarya in 1996 (Jerusalem)

Every person should view himself all year as if he were half innocent and half guilty. And that is the way he should look at the world as well, as if it were half innocent and half guilty

The term “Aseret Yemei Teshuvah” is not found in the Talmud Bavli, although the days referred to are mentioned there. The expression used in the Bavli is “the ten days between Rosh HaShanah and Yom HaKippurim.” In the literature of the Geonim, we also find “the ten days from the beginning of Tishrei to Yom HaKippurim,” “the first ten days of the month of Tishrei,” “(the time) between Rosh HaShanah and Yom HaKippurim.” But the term commonly used now, “Aseret Yemai Teshuvah,” is also found in early sources. It is used in the Talmud Yerushalmi, by Pesikta Rabbati, a Midrash, and it is also found in the literature of the Geonim. But ever since the days of the Rishonim, literally the “first” or the “early” ones, referring to post-Talmudic and Geonic times; actually Torah scholars from approximately the eleventh century through the fifteenth, “Aseret Yemai Teshuvah” is the most popular title for this period of time in the Hebrew Calendar.

The special character of these days, as will be explained below, manifests itself in emphasis on “Teshuvah,” Repentance, “Tefilla,” Prayer and “Zehirut,” Spiritual Vigilance.

 

The Mitzvah of Teshuvah

The Act of “Teshuvah,” is an act applicable and appropriate for all times of the year; it is therefore not a “Mitzvat Aseh SheHaZman Garma,” a time-bound Positive Commandment. Therefore, since women are not obligated only in time-bound Positive Commandments, “Teshuvah” is applicable to men and women during the entire year.

However, in the words of the Rambam in “Hilchot Teshuvah,” “The Laws of Repentance” (2:6), “Despite the fact that “Teshuvah” and crying out to HaShem are always timely, during the Ten Days between Rosh HaShanah and Yom HaKippurim it is exceedingly appropriate, and is accepted immediately, as it says, ‘Seek HaShem when He is to be found’ (Yeshayahu 55:6).”

The source of this statement of the Rambam is Masechet Rosh HaShanah (18a) where it is written, “Seek HaShem when He is to be found–these are the days between Rosh HaShanah and Yom HaKippurim.”

The Rambam continues in “Hilchot Teshuvah” (3:4) “…Every person should view himself all year as if he were half innocent and half guilty. And that is the way he should look at the world as well, as if it were half innocent and half guilty. If he would do just one sin, he would thereby tip both himself and the entire world towards the “guilty” side, and cause it great destruction. And If he would do just one “Mitzvah,” he would tip both himself and the entire world towards the “innocent” side and cause for himself and for them salvation, as it says “The Righteous Person is the Foundation of the World”–because his being righteous tipped the world for good, and saved it.”

“And because of this, the whole House of Israel have accustomed themselves to give more “Tzedakah” (Charity), and to do more good deeds, and to engage in “Mitzvot,” from Rosh HaShanah through Yom HaKippurim more then, than the rest of the year. And they have all adopted the custom of rising at night during this ten-day period and praying in the synagogues prayers of supplication and entreaties until daylight.”

In our time, most communities rise up early in the morning, except on Shabbat and Yom Tov, to say “Selichot,” special prayers composed over the generations by religious and literary geniuses, capturing the penitential spirit appropriate for the occasion.

 

Fasting as Part of the “Teshuvah” Process

Fasting is a classic response of the Jewish People to danger, as we see in Megilat Esther, where Queen Esther decreed three days of fasting by the Jewish citizens of Shushan when she learned of Haman’s genocidal plot against the Jews, before she took the dangerous step of entering the King’s Throne-Room without being invited.

Stressing the point of Fasting on Shabbat, which is in general viewed as contrary to the Spirit of the Day, Rav Natronai Gaon said …”These days are different from the rest of the year, and hence our ancestors were accustomed to fast during this period, both on Shabbat and on the weekdays.”

However, both Geonim and Rishonim objected to the idea of fasting on “Shabbat Shuvah,” the Shabbat between Rosh HaShanah and Yom HaKippurim, and especially to fasting on Rosh HaShanah itself. The principal objection to fasting on Rosh HaShanah is based on an explicit verse in the Book of Nechemiah 8:10, where we find Ezra telling the Jewish People, “Go, eat fat meat and drink sweet wine …, for today is holy to our L-rd.”

Rav Hai Gaon expresses doubt even about fasting on the weekdays, for these Ten Days were set aside as a time of Prayer and Confession, and of Return to HaShem in one’s heart. However, those who wish to and are able to fast on these days, may do so.

 

“Shabbat Shuvah”

The special character of this Shabbat, as opposed to all others, is that it is focused on assembling congregations of the Jewish People not only to commemorate HaShem’s Act of Creating the Universe and of His taking the Jewish People out of Egypt, but also to direct their attention to the need to Return to Him. Thus the custom of the Shabbat Shuvah Drashah, an inspirational sermon delivered by the religious leader of the community, usually combining “Halachah” and “Aggadah,” but the basic purpose of which is to provide “Hitorerut,” inspiration, that will cause the listeners to examine their deeds and return to HaShem.

In the Halachic Literature, we find the following remarks by the “Mateh Moshe,” “It is customary (that the Rav) deliver a talk on this Shabbat … in order to awaken the People to Repentance; and I have found support for this custom in ‘Midrash Mishlei,’ where it is written, ‘The Holy One, Blessed Be He, said: When the “Chacham,” or “Sage,” sits and teaches (“doresh”), I cancel and forgive the trespasses of Israel.” Hence it is proper to deliver a talk on this Shabbat, in order that He pardon their sins; and you may find another support for this in the Zohar on Parshat Vayikra.”

“The ‘Mateh Ephraim’ writes, ‘It is the custom throughout Israel, in all the places of their dispersion, that the Rav of the City deliver a talk on that Shabbat before the assembled multitude, and many books mention the fact that this ‘Drashah’ should aim at awakening the heart to Teshuvah, with words of admonition and moral teaching … in any case, the great and righteous men of each generation have always spoken to the People (on Shabbat Shuvah) with eloquence and profundity and Halachic discourse.’ ”

As mentioned, the “Shabbat Shuvah Drashah” is an ancient tradition. Moshe Rabbenu probably delivered one on the Plains of Moav, and most of the righteous leaders of Israel who followed him, probably did the same.

 

An Early Shabbat Shuvah Drashah

One of the most inspiring “Drashot” ever given to the People of Israel came from the mouth of Hoshea, the Prophet and his close contemporary, the Prophet Yoel. The Haftarah read on this Shabbat opens with a section from Hoshea, beginning with, “Return, O Israel, for you have stumbled in your sin.” (Hoshea 14:2) After reading the fourteenth and last Chapter of Hoshea, many communities continue with a portion from the Prophecy of Yoel beginning,

“Blow the Shofar in Zion,

Proclaim a Sanctified Day of Fasting;

Call for an Assembly.”

“Gather the People, Sanctify the Congregation,

Assemble the Elders;

Gather the Children and those who Nurse from the breast;

Let the Groom go out of his room, and the Bride,

From her Bridal-Canopy.”

(Yoel 2:15-16)

and ending,

“And you shall know

That I am in the midst of Israel,

And I am your G-d,

And there is no other.”

(Yoel 2:27)

Sukkot and the Purpose of Life

0
Succos Inspired: Discovering depth, joy and meaning

By: Rabbi Moshe Gersht

On Yom Kippur, we disengage from the normal lives that we live and enter a place of holiness. We don’t eat or drink, we wear white to symbolize our angelic origins and we spend the majority of the day in prayer. Then, before you know the holiday of Sukkot arrives and we’re singing and dancing, eating and drinking, and having the time of our lives partying in the sukkah.

What is the secret behind this extreme shift in our overall approach to the holidays? The answer is hidden within one of the philosophical foundations of Judaism.

When I was a young student I recall my teacher once asking us, “Gentlemen, how much do you have to change yourself for it to be considered a valuable change?” One after another, students would suggest different ways to measure the success of true growth and inner change. After a few minutes he silenced the class and said, “From now on I want you to remember, there is no such thing as small change – all change, even in the little things, has a big impact.”

What does it mean to be holy? Kedusha–holiness is often misunderstood. There is a notion that holiness means to be totally disconnected from mundane reality; that it is sacred and something completely elevated. When we think of holy imagery we may imagine a monk sitting on the mountain top meditating and speaking gently, or someone else who stands detached from the day-to-day grind of work, computers and technology, changing diapers and cooking.

Nothing could be further from the truth. To truly be holy means to be fully and passionately connected and identified with our inner self, while at the same having the capacity to express that through our day-to-day life.

The opposite of the word kodesh – holy, is the word chol – mundane. Interestingly, chol is also the same Hebrew word for sand. Why? Sand is unique from dirt in that no matter how much water you use to make the pieces stick, they ultimately remain separate entities and never really connect or join together. To be mundane means to be disconnected from our true purpose and meaning in life. The opposite is holiness which ultimately is the passionate connection to our soul, God and the pervasive purpose that exists within the fabric of creation.

On Yom Kippur, we temporarily leave the world behind and elevate our body to the place of our soul. We stop engaging in the material world by refraining from wearing comfortable shoes, showering, eating or drinking and spend the majority of the day in spiritual pursuits. Though we may see this as the holiest of holidays – the word choice of God in the Torah is tahara (see Leviticus 16:30) which means cleansing and healing.

But on Sukkot, we don’t bring our body up to our soul, rather we bring our newly cleansed and clarified soul and vision back down into our body. We are meant to ask ourselves the question: “Now that I went through the ten days of repentance, how can I bring that down into my day to day life – to live as an expression of my deepest self?” The answer to that question is in the Sukkah.

The sukkah is a place where everything we do from eating and drinking to sleeping and shmoozing becomes elevated and sanctified because it’s being done within the context of a mitzvah, a divine commandment. The mitzvah of living in the sukkah affords us the opportunity to see what life would be like if everything we did was connected with true depth, beauty and meaning.

The Torah teaches us that to truly be a holy person, we need not run away from the world and up towards the soul, rather we must grab the world with all of its glory, identify and fill it with the majesty of our own unique divinity. This Sukkot, let us take the time to remember how high we reached on Yom Kippur and find many ways to channel those moments into our day to day lives and elevate even the little things.

Adapted from Succos Inspired: Discovering depth, joy and meaning.

(Aish.com)

ABCs of Yom Kippur

0
Jews from the entire spectrum of the universe gather together to pray intently on Yom Kippur. Photo Caption–Pinterest

Guidelines for the holiest day of the Jewish year

By: Rabbi Shraga Simmons

Following the sin of the Golden Calf, Moses pleaded with God to forgive the people. Finally on Yom Kippur, atonement was achieved and Moses brought the second set of Tablets down from Mount Sinai.

From that day forward, every Yom Kippur carries with it a special power to cleanse our mistakes (both individually and collectively) and to wipe the slate clean.

This works on two conditions:

(1) We do a process called teshuva – literally “return.” Teshuva involves four steps:

  • Regret – acknowledging that a mistake was made, and feeling regret at having squandered some of our potential.
  • Cessation – Talk is cheap, but stopping the harmful action shows a true commitment to change.
  • Confession – To make it more “real,” we admit our mistake verbally, and ask forgiveness from anyone we may have harmed.
  • Resolution – We make a firm commitment not to repeat the harmful action in the future.

(2) Though the combination of teshuva and Yom Kippur atones for transgressions against God, it does not automatically erase wrongs committed against other people. It is therefore the universal Jewish custom – some time before Yom Kippur – to apologize and seek forgiveness from any friend, relative, or acquaintance whom we may have harmed or insulted over the past year.

 

Angel for a Day

On Yom Kippur, every Jew becomes like an angel. In the Jewish understanding, angels are completely spiritual beings, whose sole focus is to serve their Creator. The Maharal of Prague explains:

All the mitzvot that God commanded us on [Yom Kippur] are designed to remove, as much as possible, a person’s relationship to physicality, until he is completely like an angel.

Just as angels (so to speak) stand upright, so too we spend most of Yom Kippur standing in the synagogue. And just as angels (so to speak) wear white, so too we are accustomed to wear white on Yom Kippur. Just as angels do not eat or drink, so too we do not eat or drink.

This idea even has a practical application in Jewish law: typically, the second verse of the Shema, Baruch Shem, is recited quietly. But on Yom Kippur, it is proclaimed out loud – just like the angels do.

 

Five Aspects

There are five areas of physical involvement from which we refrain on Yom Kippur:

  1. Eating and drinking
  2. Washing
  3. Applying oils or lotions to the skin
  4. Marital relations
  5. Wearing leather shoes

Throughout the year, many people spend their days focusing on food, work, material possessions (symbolized by shoes) and superficial pleasures (symbolized by anointing). On Yom Kippur, we restore our priorities to what really counts in life.

As Rabbi Eliyahu Dessler writes:

On Yom Kippur, the power of the [physical] inclination is muted. Therefore, one’s yearning for spiritual elevation reasserts itself, after having lain dormant as a result of sin’s deadening effect on the soul. This rejuvenation of purpose entitles a person to special consideration and forgiveness.

 

Structure of the Day

On Rosh Hashana, the Books of Life and Death are open and God writes who will be granted another year of life. For many, this decision hangs in the balance for nine days until Yom Kippur, when the final decision is sealed. With this in mind, the prayers of Yom Kippur are designed to stir us to mend our ways:

  • The Yom Kippur prayers begin before sundown with the haunting melody of Kol Nidrei. The Torah scrolls are all removed from the Ark, and the chazzan (cantor) chants the Kol Nidrei prayer three times, each with greater intensity.
  • The special Yom Kippur Amidah (standing prayer) incorporates the Al-Chet confession of our various mistakes. With each mention of a mistake, we lightly beat our chest with the fist – as if to say that it is our impulses that got the best of us.
  • The Yizkor service – said in memory of loved ones – is recited following the morning Torah reading.
  • The lengthy Mussaf service features a recounting of the Yom Kippur rite in the Holy Temple in Jerusalem. A highlight was the High Priest entering the Holy of Holies – the only person to do so, this one time a year. The Mussaf service also records how the High Priest would pronounce God’s holy name, and in response the assembled Jews would prostrate on the ground. When reaching these passages, we too prostrate ourselves on the ground.
  • At the Mincha service, we read the Book of Jonah, the biblical story of a prophet who tried to “flee from God” and wound up swallowed into the belly of a huge fish.
  • While a regular weekday has three prayer services, and Shabbat and holidays have four, Yom Kippur is the only day of the year that has five. This final prayer is called Ne’ilah, literally the “closing of the gates,” which serves as the final chance to ensure that our decree for the year is “sealed” in the Book of Life. At the conclusion of Ne’ilah, the shofar is sounded – one long blast, signifying our confidence in having passed the High Holidays with a good judgment.

 

The Fast Itself

  • The Yom Kippur fast begins before sundown, and extends 25 hours until the following nightfall.
  • During the afternoon hours leading up to Yom Kippur, it is a special mitzvah to eat a festive meal.
  • For making your fast easier, hydration is the key. Avoid coffee or coke, because caffeine is a diuretic. Heavy coffee drinkers can also avoid the dreaded headache by slowly reducing the amount of consumption over the week leading up to Yom Kippur. (See Aish’s “Guide to http://www.aish.com/h/hh/yom-kippur/guide/Seven_Steps_to_an_Easy_Fast.html an Easy Fast”)
  • At the festive meal, eat a moderate portion of food so as not to speed up the digestion process. After you complete the festive meal, leave some extra time before sundown to drink.

 

In Case of Illness

  • If someone is ill, and a doctor is of the opinion that fasting might pose a life-danger, then the patient should eat or drink small amounts.
  • The patient should try to eat only about 30 ml (one fluid ounce) and wait nine minutes before eating again. Once nine minutes have passed, one can eat this small amount again, and so on throughout the day.

             (Aish.com)

9 Lesser Known Facts about Yom Kippur

0
While Jews generally do not kneel in synagogue, on Yom Kippur and Rosh Hashanah it’s customary to kneel at several key points in the service.

Here are nine often overlooked facts about Yom Kippur
to enhance your experience of the Jewish day of repentance.

Dr. Yvette Alt Miller

  1. We eat a holiday meal before Yom Kippur begins.

Yom Kippur is marked by fasting, but before it begins we enjoy a special festive meal. It’s customary to set our tables beautifully the way we would for Shabbat or another holiday and to eat together with family or friends. This special afternoon meal before the fast begins allows us to joyfully celebrate the holiday, as well as strengthening us for the rigors of the fast to come.

This meal – called seudah hamafseket, or meal of cessation in Hebrew – has to be concluded while it’s still light outside and should contain no alcohol, garlic or heavily spiced foods.

  1. We act like angels.

Jewish tradition records that God first informed the heavenly angels that He intended to create mankind. The angels were horrified and asked God why He would create such flawed beings; weren’t the perfect angels enough? God replied: although mankind is flawed, human beings still have the ability to achieve greatness through their free will, achieving spiritual heights that perfect angels who lack free will can never scale.

On Yom Kippur, we recognize our ability to achieve perfection by acting like angels who do no wrong. Many Jews wear white clothes like angels. We fast as if we were living entirely on a spiritual plane. For one day, we leave behind the physical and focus purely on our spiritual selves.

  1. Food isn’t the only luxury we give up.

On this holiest day, we give up food and drink. We also don’t bathe or anoint ourselves, nor wear leather shoes and engage in marital relations. It’s a day to downplay our physical needs and pleasures and focus on our spiritual sides instead.

  1. Some people are obligated to eat.

The mitzvah, or commandment, of saving a life takes precedence over just about all commandments in Judaism. If someone has an illness or other medical condition that makes it dangerous to fast, then not only are they exempt from fasting on Yom Kippur: they are positively commanded to eat to preserve their life. If you have any question about fasting, be sure to speak with a doctor and a rabbi about this imperative to preserve your health.

  1. Regretting our sins isn’t always enough.

While Yom Kippur is a day of forgiveness, when it comes to atoning for things we’ve done to another person, we’re required to reach out and apologize and seek forgiveness to those we’ve harmed. Sins between man and God can be atoned for through prayer and sincere teshuva, repentance, but if the pain we’ve caused another person can be remedied – for instance by paying to fix something we’ve broken – we have an obligation to do that too before we can truly be forgiven.

  1. Yom Kippur’s deep connection to Purim.

Purim seems to be the opposite of Yom Kippur: it’s a joyous spring holiday marked by lots of spirited singing, dancing, giving presents, eating and drinking. Yet Jewish tradition teaches that Purim is fundamentally linked with Yom Kippur.

Yom HaKippurim means both “Day of Atonement” and “a day like Purim”. Both paths allow us to bring spirituality into our lives and elevate ourselves using radically different methods: Purim through engaging all our physical senses and Yom Kippur by denying and downgrading our physical sides.

  1. We kneel in synagogue.

While Jews generally do not kneel in synagogue, on Yom Kippur and Rosh Hashanah it’s customary to kneel at several key points in the service. This departure from ordinary custom underlines the specialness of this holy day and recalls the ancient service in our holy Temple in Jerusalem, when the Kohen Gadol, the High Priest, would prostrate himself during some points of the service.

  1. The term “scapegoat” originates on Yom Kippur.

The term “scapegoat” originates with the Yom Kippur service. In ancient times, the Kohen Gadol would take a goat and confess the sins of the entire people of Israel over it before driving it away into the desert and off a cliff (Leviticus 16:1-34). We read of this ancient ritual on Yom Kippur morning, as we pray that our sins will similarly be banished and forgotten today.

  1. The night after Yom Kippur is a holiday too.

Starting the year with a clean slate, the evening after Yom Kippur is considered a holiday. It’s customary to eat a festive holiday meal and to wish each other holiday greetings.

Many Jews recite a beautiful prayer over the new moon after Yom Kippur services, and Jews all over the world spend the evening preparing for the next big Jewish holiday: Sukkot, just four days away.

             (Aish.com)

Book a Fabulous Fashion Tour in Tel Aviv or Jerusalem

0
Liraz Cohen, right, leading a Fashionating by Liri tour in the Jaffa district of Tel Aviv. Photo by Shany Reich

Tailored tours of emerging Israeli clothing,
accessory and jewelry designers open an exciting new window onto Israeli innovation and style

By: Abigail Klein Leichman

Swimsuits by Gottex, wedding gowns by Galia Lahav and red-carpet dresses by Shahar Avnet: Israeli fashion has made its mark internationally as growing numbers of celebrities don designs dreamed up by Israelis.

A map of designers in the Noga neighborhood of Tel Aviv.

Those of us who don’t have the glam (or budget) of Beyoncé or Rihanna can still find our fit from Israeli designers — if we just know where to look.

ISRAEL21c recently took three fashion tours led by Israeli insiders eager to share their passion for fashion with locals and especially with visitors from abroad as part of their trip itinerary. A fourth tour option, dedicated specifically to Israeli fashion, food and culture, is led by the former owner of a New York City boutique specializing in Israeli designers.

Any of these fun tours will deepen your appreciation of Israeli creativity. Should you fall in love with an outfit or accessory to take home, all the better!

At the end of this article you’ll find links to the websites of more than 20 young Israeli designers on the radar of our fashion tour guides. In a future ISRAEL21c article we will take a closer look at several of the clothing designers we visited.

 

TLVSTYLE (Galit Reismann)

We begin our fashion travelogue in Tel Aviv, the undisputed – but not exclusive – fashion capital of Israel, where we meet fashion tour pioneer Galit Reismann in the Noga neighborhood near Jaffa. Thirteen clothing designers and half a dozen shoe, bag and jewelry designers have studios dotting this quaint district.

Over a cup of coffee before we start walking, Reismann explains that in 2012, after five years of transatlantic travel running trade shows for a distributor of Israeli fashion in the United States, she decided to stay home and invent a new niche: TLVStyle fashion tours of Tel Aviv.

Galit Reismann of TLVStyle modeling a kimono by Shahar Avnet. Photo by Noa Magger

“I’m a people person. I love Tel Aviv and its creative people, and I love working with international people. I create bridges between them,” Reismann says.

Often working in cooperation with tour operators and the ministries of Tourism and Foreign Affairs, this Israeli fashion maven has taken groups and individuals from 15 countries on half-day explorations of small studios producing cutting-edge clothing, accessories and jewelry.

Reismann focuses on up-and-coming graduates of fashion programs at prestigious Israeli institutions such as Shenkar College of Engineering and Design.

“Since Israel is a young country and we don’t have a fashion heritage, I decided to build my fashion tour through the Israeli identity and through the young emerging designers who are the voice of the future in Israel,” she says.

“I want to show the human stories by bringing people to meet designers in their ateliers. When they buy something and share its story with people at home, they become an ambassador for Israel. But you don’t have to buy anything. A fashion tour with me is like a culinary tour. You need to experience it and celebrate it.”

Although about 90 percent of her clients are female, she has some exciting menswear designers on her itinerary and always welcomes male participation.

A questionnaire inquiring about everything from taste in fashion to taste in music helps her tailor each itinerary.

“Every tour is different but all show inspiration, creativity and innovation. The main core mission of the tours is to inspire you and educate you,” Reismann tells ISRAEL21c. Stops can include designers of accessories and jewelry.

In between studios, Reismann sparks conversations about slow fashion, sustainability, entrepreneurship, glocalization, innovation vs. craft, and coexistence in fashion. These are the values she also incorporates into Israeli fashion talks she gives overseas.

In honor of International Women’s Day in March 2020, Reismann will partner with Israel Unlimited Boutique Tours in “Shades,” a weeklong event for 16 women exploring Israeli culture through fashion, art, cuisine and luxury lifestyle in different cities and ethnic communities.

Contact Reismann here at [email protected] for more information.

 

FASHIONATING BY LIRI (Liraz Mordechai Cohen)

Fun fact: The modern Hebrew word for “fashion,” ofna, was coined by Hemda Ben-Yehuda, wife of Eliezer Ben-Yehuda, the man who revived the Hebrew language in the 19th century. She even wrote a fashion column under a pen name.

That is one of many interesting historical tidbits ISRAEL21c learned during a tour of emerging clothing and jewelry designers in Jerusalem with Ilan Pelleg Dotan of Fashionating by Liri.

Liraz Cohen modeling one of Jerusalem fashion designer Adi Yair’s black-and-white woven creations at Beit Alliance, a historic building with studios for artists and musicians. Photo: courtesy

Fashionating tours of Tel Aviv and Jerusalem grew out of Liraz “Liri” Cohen’s lectures and runway shows across the United States highlighting Israeli fashion past and present. A stylist and blogger with a master’s degree in fashion merchandising from New York’s Fashion Institute of Technology, Cohen splits her time between Tel Aviv and New York.

“Liri tells the story of Israel through the unique perspective of fashion. It’s relatable and fun,” says Dotan, a Shenkar fashion design graduate and Fashionating by Liri’s director of Israeli programs. “People from her audiences told her that they wanted to come to Israel and see the designers, so in 2016 she decided to lead fashion tours to Israel.”

A variety of itineraries includes sustainability and fashion, technology and fashion, startups influencing the future of fashion, and local designers. Luxury brands, sustainable brands and a tour geared to fashion industry professionals are among the options.

The Jerusalem tours, begun this July, weave in the narrative of how 2,000 years of history and spirituality influenced the unique fashion flavor of the capital city. Many of the pieces we saw were black and white, perhaps inspired by the religious garment palette – think of the tallit (prayer shawl).

“When we told designers we are starting tours in Jerusalem they were so happy; it was like they were waiting for someone who will let them speak and share their inspiration,” Cohen says.

The designer fashion scene in Jerusalem is centered around trendy Bezalel Street, original location of Bezalel Academy of Art and Design established in 1906. Today that campus houses Bezalel’s architecture program and the fashion design program is based on the Mount Scopus campus. However, this is the district where many Bezalel graduates return to launch their clothing and jewelry.

Dotan, a kibbutz-raised Israeli whose English is fluent thanks to her American mother, imparted lots of interesting information about Israeli fashion history and Jerusalem’s emerging designers. We received a take-home packet including contact information for the designers we visited, among other goodies.

Get info on Fashionating by Liri tours here.

 

MOD STYLISTA (Devora Golan)

Another new tour of the Jerusalem fashion scene comes from a different angle, that of professional personal stylist Devora Golan, who moved to Israel from the United States in 2007.

In addition to doing personal shopping, wardrobe and event fashion consultation for private clients from secular to ultra-Orthodox, earlier this year Golan launched tours in Jerusalem that combine the stories of several designers with styling and shopping guidance for each participant.

Fern Penn, third from left, and Rosebud Fashion Tour participants flanking Sharon Tal, head designer of Israeli fashion house Maskit. Photo: courtesy

She accepts individuals and small groups; a short questionnaire helps her determine your style and what items of clothing or accessories you’re seeking.

“People always say they don’t know where to shop here and I want them to see that there are so many amazing designers and good-quality pieces for a range of budgets,” says Golan.

For now, her itinerary includes four clothing stores, one accessory store and one jewelry store in downtown Jerusalem. She plans to build tours in other Jerusalem neighborhoods such as the German Colony, and in other cities such as Tel Aviv and Petah Tikva.

“The added value is that you’re getting my expertise about what will look good on you,” says Golan, who greeted us with a gift of a Mod Stylista bottle filled with cold water – a must for walkers around Israel and a useful keepsake.

You can follow Golan on Instagram (@modstylista) and book a tour by emailing [email protected].

 

ROSEBUD FASHION TOUR (Fern Penn)

In 2003, New Yorker Fern Penn opened Rosebud, the first store in the United States to offer women’s designer clothing, accessories, home accessories and art all designed and manufactured in Israel.

For 15 years, Penn made buying trips to Israel several times a year for Rosebud, first located in Soho and then on Madison Avenue. As Manhattan rents rose steeply, Penn decided to close her shop and instead offer small groups of women exclusive week-long tours exploring the fashion and design scene in Tel Aviv, Jaffa and Jerusalem.

The first tour, in November 2018, featured emerging designers such as Adi Benjo and Naomi Maaravi along with established designers such as Kedem Sasson and Ronen Chen.

“By the time we went home, everyone had to buy an extra suitcase,” Penn tells ISRAEL21c.

The Rosebud itinerary also includes design museums, street art, open-air markets, galleries and upscale kosher dining. The next tour is planned for March 2020.

   (Israel 21C)

NYC Health + Hospitals/Bellevue Designated with Provisional Status as Level II Pediatric Trauma Center

0
NYC Health + Hospitals/Bellevue has been a Level I Adult Trauma Center for decades, delivering state-of-the-art, around the clock trauma care. Photo Credit: NYC Health + Hospitals

NYC Health + Hospitals/Bellevue is the only Level I Adult Trauma Center and Level II Pediatric Trauma Center south of 68th Street

Edited by: JV Staff

NYC Health + Hospitals/Bellevue announced last week that the New York State Department of Health has formally designated the hospital with provisional status as a Level II Pediatric Trauma Center. With the new designation, the hospital’s pediatric emergency room has begun treating trauma patients under age 15, ensuring that New Yorkers of all ages get the most advanced and timely trauma care possible. Prior to this provisional status, pediatric trauma patients were transferred to a nearby hospital for care. NYC Health + Hospitals/Bellevue is the only Level I Adult Trauma Center and Level II Pediatric Trauma Center south of 68th Street.

“NYC Health + Hospitals/Bellevue has the resources to provide the most advanced and timely care for New York City’s children,” said Machelle Allen, MD, Senior Vice President and Chief Medical Officer of NYC Health + Hospitals. “This new designation is allowing us to broaden our services within the pediatric subspecialties, complementing NYC Health + Hospitals/Bellevue’s high quality pediatrics and pediatric intensive care services.”

“Our Level II Pediatric Trauma Center designation is significant because, once stabilized, pediatric trauma patients no longer need to be transferred to another hospital,” said Sandra Tomita, MD, Pediatric Trauma Medical Director at NYC Health + Hospitals/Bellevue. “Now, pediatric trauma patients are able to receive specialized treatment and take advantage of our expertise in trauma care.”

“A Level II Pediatric Trauma Center requires first and foremost, commitment. NYC Health + Hospitals/Bellevue has the resources and committed staff to care for injured children,” said Spiros Frangos, MD, Chief of Surgery, and Division Chief of Trauma, Emergency Surgery, and Surgical Critical Care.

“Our central location in midtown Manhattan allows patients to be transported quickly, allowing us to get to the most traumatic patients in a timely fashion, as time is life. In the unfortunate event that members of the same family are injured, Bellevue can now treat members of the same family without having to transfer and separate pediatric trauma patients from their parents,” said Blanca Agosto, RN, Pediatric Trauma Program Manager.

Since being designated a provisional pediatric trauma center earlier this year, NYC Health + Hospitals/Bellevue has received and treated more than 50 pediatric trauma patients and is on the way to surpass Level II patient qualifications of treating at least 100 patients annually.

Over the next three years, Dr. Sandra Tomita and Blanca Agosto will spearhead efforts to attain Level II pediatric trauma verification from the American College of Surgeons (ACS). During this time, the Pediatric Trauma Program will continue to treat children with traumatic injuries. NYC Health + Hospitals/Bellevue will have provision status as a Level II Pediatric Trauma Center for three years, during which it will continue to treat children with traumatic injuries.

NYC Health + Hospitals/Bellevue has been a Level I Adult Trauma Center for decades, delivering state-of-the-art, around the clock trauma care.

Trauma, accidental or intentional injuries that require immediate attention are best cared for at trauma centers. Injured pediatric patients require specialized treatment and NYC Health + Hospitals/Bellevue’s Pediatric Trauma program includes a specially trained multidisciplinary healthcare team of physicians, nurses, social workers, and rehabilitation therapists. This team includes pediatric specialists in surgery, emergency care, anesthesiology, neurosurgery, orthopedic surgery, plastic surgery, and otolaryngology. Services include a dedicated pediatric emergency room, pediatric intensive care unit, and pediatric transport.

Trauma is the leading cause of death between the ages of one and 14 years old nationwide, and results in temporary or permanent disability for millions of infants and children annually.

 

About NYC Health + Hospitals/Bellevue

NYC Health + Hospitals/Bellevue is America’s oldest public hospital, established in 1736. Affiliated with the NYU School of Medicine, the 844-bed hospital is a major referral center for highly complex cases, with 6,000 employees including highly skilled, interdisciplinary clinical staff. It is a Level 1 Trauma Center and sees more than 110,000 emergency room visits and more than 444,000 outpatient visits annually. Clinical centers of excellence include: Emergency Medicine and Trauma Care; Cardiovascular Services; Bariatric Surgery; Designated Regional Perinatal Center and Neonatal Intensive Care Unit (ICU); Children’s Comprehensive Psychiatric Emergency Program; and Cancer Services. For more information, visit www.nychealthandhospitals.org/bellevue or find us on twitter.com/BellevueHosp.

 

About NYC Health + Hospitals

NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs. A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system’s trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan—all supported by 11 essential hospitals. Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. For more information, visit www.nychealthandhospitals.org and stay connected on Facebook at https://www.facebook.com/NYCHealthSystem or Twitter at @NYCHealthSystem.
Visit www.nychealthandhospitals.org

Manhattan Apt Sale Prices Hit Five Year Low;  Mansion Tax Cited

0

Sales of luxury apartments in the Big Apple seem to have slumped.  As per a report by the Wall Street Journal, apartment sale prices in Manhattan fell in the third quarter of this year, reaching their lowest level in the past four years.  Overall residential sales in the third quarter fell by 11.5% compared with the levels in the same quarter in 2018, according to the report. “Even with the rush before the taxes and hangover afterwards, we are still in a sluggish market,” said Gregory J. Heym, the chief economist for brokerage firms Halstead and Brown Harris Stevens. 

By Ilana Siyance

As per Crain’s NY, the decline in prices is being attributed to the new tax increases for residential real estate costing over $1 million. As of July 1st, a mansion tax came into effect, charging homebuyers paying $1 million or more, an extra 1 percent over the purchase price. The added tax grows incrementally, with 8 individual tax brackets, charging a high of 3.9 percent for homes selling for $25 million or more. Formerly, the mansion tax rate was at 1 percent across the board, meaning that the highest 25 million mark saw a tax increase of nearly 3 percent.   As an example, a NYC condo purchased for $2,500,000 will now incur a mansions tax due for $31,250, at a rate of 1.25 percent. 

Also added was a transfer tax, which starts at 1.4 percent for homes that cost below $500,000 and reaches up to about 2 percent on homes priced at $25 million.  The transfer tax is customarily paid by the seller, while the Mansion Tax is paid by the seller, within 15 days of closing. The tax increases were imposed in April, as part of the 2020 New York State budget.  It is part of an effort to increase funding for mass transit, and the MTA’s crumbling subway system.  

 Before the taxes came into play, million-dollar real estate transactions in Manhattan were booming. The median sales price for apartments jumped almost 20% to $1.4 million in the second quarter.  Then, at the start of the third quarter, the tax become effective, and the sales prices tumbled 25 percent to just above $1 million, which is the lowest median prices have been since 2015.

 The new report is sure to be a disappointment to real estate developers who have been in a mad dash to complete their new ultra-luxury residential sky-scrappers which were conceived during the real estate uptick.  Last month, a study by Street Easy revealed that roughly 25 percent of the new condos built in NYC since 2013 have yet to be sold.

What is a Hernia? – A Laparoscopic Surgeon Tells All

0
An anatomical representation of the lower abdominal wall, demonstrating the muscular layers, as well as the orifices and tubes that normally travel thru them.

By: Dr. Anthony Vine

What is a Hernia? As a Laparoscopic General Surgeon, I am able to care for complex intestinal problems— diverticulitis, colon cancer, Crohnʼs disease, gastroesophageal reflux (GERD)—with a television camera and tiny scars, but perhaps one of the most common patient issues that faces me every day is a hernia. What is a hernia? Do all hernias need to be fixed? Can and should hernias be repaired laparoscopically? What is mesh made of, and is it safe to deploy in the human body? These are just a few of the questions that as doctors, we must explain to our patients. 

Because we could write volumes on the topic of hernias, I will limit todayʼs discussion to the definition and development of a hernia, and leave the issues of surgical treatment to a subsequent article. At this point, before I answer any of the above questions, I should digress and elucidate for you the origins of the words “doctor” and “patient.” 

I must confess that my route to becoming a surgeon was via several years of ancient Greek and Latin studies at Phillips Academy and as an English Literature major at Princeton University, prior to attending Vanderbilt University School of Medicine. Subsequently, I trained at Mount Sinai Hospital, NY in General Surgery and attended the Massachusetts General Hospital for a research fellowship in cardiovascular surgery. I was not your usual biochemistry major: rather, I took a more humanistic approach to the practice of medicine and surgery. Linguistically speaking, the two words are derived closely from Latin. 

The first, “doctor,” is from “doceo, docere, doctus,” meaning “to teach,” while the latter stems from the verb “pateo, patere, passus (sum)”—“to suffer.” So, in essence, a doctor is one who teaches, and a patient is one who suffers. Now that we have our definitions, I can teach you, as I would to a patient sitting across the desk from me in my office, what a hernia is and why someone may be suffering from this ailment. 

Simply stated, a hernia is a hole or weakness in the musculature of the abdomen, allowing either fat or an organ to protrude, to travel from inside one space to another space. I will even go so far as to say that many hernias are really just normally occurring holes that Hashem created in our bodies, but that the holes have become too wide or too large, and are now allowing other entities to process through such an enlarged orifice. 

Why did Hashem make these holes in our body? Was it a mistake or an error, an oversight during creation? Hardly. These holes allow conduits or tubes (remember, a surgeon is merely a plumber of sorts)—arteries, veins, bowels, nerves—to traverse from one part of the body to another. For example, if we did not have a hole in our diaphragm muscle, then the esophagus would never connect to the stomach, and we would be unable to eat by swallowing our food. If the hole through which the esophagus travels becomes wide over time, then the stomach can migrate up above the diaphragm into the chest, causing, in many cases, food regurgitation, heartburn (acid reflux), chest pain, bad breath, and many other symptoms. 

So, what is an inguinal hernia? When we are in the womb, men and women undergo development of their respective gonads. In a male, the testicle is originally part of the lower aspect of the kidney: it breaks away, takes along with it its artery and veins, and on the way, joins up with the vas deferens (aka, the spermatic cord). This complex then pushes its way through the abdominal muscle in the groin (“inguinal” canal), and takes every layer of the abdominal wall along with it to create the protective housing called the scrotum (if you look at the scrotum under a microscope, it has the same six layers of the abdominal wall). 

Now, if the abdominal wall at around the time of birth does not close snugly or completely around the testicle triad of tubes, there may be a gap alongside these structures, and there we have the origin of what we call an inguinal hernia. Over one’s lifetime—even in the early months of life—intraabdominal organs (bowels, aka “kishkes,” the bladder, the appendix, etc) may protrude through this canal and cause a bulge or swelling in the groin or scrotum, either with or without symptoms, ranging from discomfort or pain, to constipation, to even bladder issues. 

Women are not immune from developing groin hernias, too, since the suspensory ligaments of the uterus (the “round ligament,” as it is called) carry the similar developmental openings in the groin area of the abdominal wall. We even see hernias in the upper thigh, called femoral hernias (this varietal fun more common in women), which travel in the space under the groin (“inguinal”) ligament medially to the iliofemoral “groin” blood vessels. Remember that if there were no window in the muscle in this region for those blood vessels, we would never be able to get blood from the abdominal aorta all the way to the legs, feet and toes! 

There are many other such hernias—epigastric, lumbar, obturator, Spigelian, just to name a few—as well as the other very common one, called an “umbilical hernia,” a result of the weak abdominal tissue where we were attached until birth to our mothers. Many individuals present with multiple hernias—weak tissue in several different areas, and there are some who develop, or acquire, hernias more acutely—such as a diaphragmatic hernia from trauma, as in a car accident or a very bad fall. Muscles can rupture from trauma and cause protrusions. People who have had prior abdominal surgery may end up with a breakdown of the abdominal closure, even many years later: we call these incisional hernias, whether they be from an old appendix scar, an open colon or stomach surgery, or even a laparoscopic incision. 

A bulge in the musculature of the upper abdominal wall that many people have when they do a sit-up may not even be a hernia at all, but rather a “rectus diastasis,” from the Greco-Latin roots, “dia-apart” and “sto-to stand”: in other words, the two abs (“six pack” muscles) are separated in the middle by a weak central tendon. Plastic surgeons may fix this, called a “tummy tuck,” but it is not a “hernia” per se—just an unsightly and perhaps demoralizing body habitus. As hernias go, most bulges without any symptoms are not surgical emergencies: however, a painful or even red lump or bulge on the abdominal wall that does not recede or get better when you are supine (lie down) should make you seek medical attention, as this may represent a hernia that is stuck (“incarcerated”) or contains choked tissue (“stangulated”): a true surgical emergency. Indeed, albeit a long lesson on hernias, we have scratched only the surface. 

In the next installment, we will consider the other questions posed above: the science behind the methods of hernia repairs; the use and safety of mesh; and the expected outcomes, including postoperative care. Wishing a Shana Tovah and good health to all.

 

Dr. Anthony Vine is a laparoscopic surgeon in NYC. He attended Phillips Academy, Princeton University and Vanderbilt Medical School, with surgical residencies at Mount Sinai Hospital (NYC) and Massachusetts General Hospital (Boston). His expertise includes: GERD and other esophageal diseases (achalasia, cancer), hernia surgery, colon surgery (cancer, diverticulitis) and inflammatory bowel disease (Crohn’s, ulcerative colitis). In addition to being one of New York Magazine’s “Best Doctors” and a long-standing Castle Connolly “Top Doctor,” he continues to play violin both professionally and as an amateur, having performed at the Verbier Festival (Switzerland) and with the Roosevelt Island concert series (NYC, RRconcerts.org).

Filmmaker Kevin Smith: Harvey Weinstein “Made Me Sick” After Scheming Phone Call

0
Writer-director Kevin Smith wants everyone to know how sick Harvey Weinstein makes him. Smith recently told Business Insider in an interview that he was surprised to receive a phone call from the controversial movie executive back in the autumn of 2017. Photo Credit: Shutterstock

Writer-director Kevin Smith wants everyone to know how sick Harvey Weinstein makes him.

By: Patrick McGuire

Smith recently told Business Insider in an interview that he was surprised to receive a phone call from the controversial movie executive back in the autumn of 2017. As he mentioned, the pair had not spoken since 2008 when they had worked together on the forgettable Zack and Miri Make a Porno, featuring Seth Rogen and Elizabeth Banks. Fourteen years earlier, Weinstein had purchased Smith’s movie Clerks.

“I said, ‘Hey, how are you?’ And he goes, ‘You know, we have ‘Dogma,’ (starring Ben Affleck and Matt Damon) I just realized, and we got to get it out there again,'” Smith, whose Jay and Silent Bob Reboot will debut in October, told Business Insider.

“I said, ‘We do! People online are always asking where they can get it,'” Smith said. “And he then goes, ‘You know, that movie had a big cast, we might even be able to do a sequel.’ And I was like, ‘Yeah man, right on. I might think about that.’ And he was like, ‘We’ll talk.’ And a week later The New York Times story breaks. I felt sick to my stomach.”

“I don’t know if that call even happened, and if it did, that there was any expectation other than making a creative business decision; it’s what Weinstein was well known for,” Weinstein’s spokesman Juda Engelmayer told Business Insider. “He was starting to circle the wagons,” Smith told Business Insider about Weinstein. “It was him looking to see who was a friend still because his life was about to shift completely. And I used to be a defense guy. I wrote a piece in Variety on how he’s still got the edge when people would go after him like, ‘Harvey’s lost his touch.'”

As Smith said in the interview, “Of all the people who have gripes against that individual — whose name used to be so easier to say — mine is a minor one and doesn’t come close to their real world issues. But the irony of having the one movie that’s about faith and spirituality locked down because of the situation that takes it out of public view is not lost on me.”

He continued, telling Business Insider, “You know, it sounds like he’s got legal bills. referring to Weinstein’s upcoming trial in January for rape and sexual assault charges. “That’s an asset you can sell to somebody.”

Zuckerberg to Battle Warren Over Facebook’s Future if She Becomes President

0
Mark Zuckerberg is not an Elizabeth Warren supporter – to say the least. In fact, he is reported to have told many of his Facebook employees he plans to “go to the mat” with her should she become president. Photo Credit: Shutterstock

Mark Zuckerberg is not an Elizabeth Warren supporter – to say the least.

By Howard M. Riell

In fact, he is reported to have told many of his Facebook employees he plans to “go to the mat” with her should she become president.

“The giant social network’s CEO, striking a defiant tone against critics at an all-hands meeting in July that was secretly captured on audio, said Facebook would fight tooth-and-nail against any attempt to break up the company,” reported the New York Post. “The 35-year-old tech tycoon added that he expects a legal challenge from Warren if she is elected to the White House, according to audio obtained by The Verge.”

“If she gets elected president, then I would bet that we will have a legal challenge, and I would bet that we will win that legal challenge,” Zuckerberg told his employees,” according to the Post. “And does that suck for us? Yeah,” Zuckerberg added. “I mean, I don’t want to have a major lawsuit against our own government.” But “if someone’s going to try to threaten something that existential, you go to the mat and you fight.”

Wrote Warren on Twitter: “What would really ‘suck’ is if we don’t fix a corrupt system that lets giant companies like Facebook engage in illegal anticompetitive practices, stomp on consumer privacy rights, and repeatedly fumble their responsibility to protect our democracy,” the Democratic presidential candidate wrote.”

Warren introduced her proposal to break up Facebook, Amazon and other tech giants in March. To get her message across, she also paid for a billboard in San Francisco that read “Break Up Big Tech,” in capital letters.

“On Tuesday, nearly seven months after Ms. Warren first unveiled her plan, The Verge offered a window into what Mark Zuckerberg, Facebook’s chief executive, thinks about it. In leaked audio recordings of open meetings with employees this summer, Mr. Zuckerberg can be heard saying that the company would sue if Ms. Warren were to enact the plan as president,” reported The New York Times. ““If she gets elected president, then I would bet that we will have a legal challenge, and I would bet that we will win the legal challenge,” he said.

“The Massachusetts Democrat and presidential hopeful for 2020 has been at the epicenter of calls to break up technology giants like Facebook Inc., as well as Google-parent Alphabet Inc. and Amazon.com Inc.,” Barron’s reported.

“Today’s big tech companies have too much power—too much power over our economy, our society, and our democracy. They’ve bulldozed competition, used our private information for profit, and tilted the playing field against everyone else,” she wrote in a March blog post on Medium.”

SI’s Rep Max Rose Shocks Dems by Not Jumping on Impeachment Bandwagon

0
Impeachment fever is running wild, but Democrat Congressman Max Rose (middle) is not caught up in it. Photo Credit: Shutterstock

Impeachment fever is running wild, but Democrat Congressman Max Rose is not caught up in it.

Which has his fellow Democrats scratching their heads.

By: Ernest McGovern

“To understand the anomaly of Representative Max Rose, one of the few House Democrats who has not endorsed an impeachment inquiry into President Trump, one must first understand a few other anomalies,” the pro-left New York Times reported. “There is the anomaly of Staten Island, the lone stronghold of conservatism within deep blue New York City, and the heart of Mr. Rose’s district. There is the anomaly of Mr. Rose himself, whose victory last year made him just the second Democrat to represent Staten Island in Congress in more than 30 years.”

That “leads to the third and current anomaly,” the Times added. “Mr. Rose’s refusal to back impeachment, amid revelations that Mr. Trump asked the president of Ukraine to investigate the former Vice President Joseph R. Biden Jr., even as most other Democrats in vulnerable seats have signed on.”

Congressman Rose released the following statement only days ago addressing the ongoing investigation into allegations against the President regarding Ukraine: “I’ve now sworn an oath to uphold the Constitution twice and I take my Congressional oath just as seriously as when I deployed to Afghanistan. That’s why I will not operate on any false timeline when our national security is at stake. My constituents—and our country—deserve Members of Congress who will review the facts and ensure the American people are fully informed. Those who would celebrate this moment or dismiss these serious allegations simply because it’s a Republican President should recognize that mindset is why the American people are disgusted with our politics.

“The transcript, whistleblower report, and the Acting Director of National Intelligence’s testimony is deeply alarming,” he continued. “This story is far from over and we must proceed in a deliberate and responsible manner that brings all the facts to the forefront and earns the trust of the American people. That’s the only way to uphold the Constitution without tearing this country apart. Under no circumstances will I allow politics to influence my decision regarding this matter.”

His stance isn’t necessarily winning him any friends in the Democratic Party. “Rose’s pitch and politics seem to match the district well: he’s a moderate, center-left politician and military veteran with a no-nonsense but affable and energetic personality,” the Gotham Gazette recently reported. “His mantra is serving constituents above political party, he regularly criticizes fellow Democrat Mayor Bill de Blasio, and he distances himself from the ascendent left-wing of his party, but sticks close to the House majority, though in fulfilling a campaign promise he did not vote for Speaker Nancy Pelosi to retain her leadership role.”

Bolton at Odds with Trump; Calls N. Korea a “Grave & Growing Threat”

0
"I informed John Bolton last night that his services are no longer needed at the White House,” Trump said at noon on Tuesday on Twitter. “I disagreed strongly with many of his suggestions, as did others in the Administration, and therefore.....I asked John for his resignation, which was given to me this morning.” Photo Credit: Shutterstock

Former national security adviser John Bolton, who was terminated from his position in the Trump cabinet a few weeks ago is apparently ready to publicly voice his disagreements with the president on foreign policy as it pertains to North Korea.

Edited by: Fern Sidman

According to a report in the Washington Examiner, Bolton addressed an audience on Monday at the Center for Strategic and International Studies; a Washington, DC think tank.  He explicated that he is speaking in the capacity of a private citizen now and as such is able to put forth his own personal opinions about the trajectory of North Korea. Saying that he would “speak in unvarnished terms” Bolton called North Korea a “grave and growing threat.” The report in the Washington Examiner indicated that the ousted national security advisor warned that North Korea has not made a strategic decision to relinquish its nuclear weapons despite Trump’s attempt to forge a relationship with dictator Kim Jong Un.

CNN reported that Trump has made repeated attempts to cultivate Kim as a friend in order to convince him to abrogate his nuclear program. 

“Under current circumstances he will never give up the nuclear weapons voluntarily,” Bolton said. 

“In fact, I think the contrary is true,” Bolton said. “I think the strategic decision that Kim Jong Un is operating through is that he will do whatever he can to keep a deliverable nuclear weapons capability.”

Bolton was proven prescient once again when on Wednesday it was reported that North Korea fired a ballistic missile from an underwater launch platform, according to a United States official who told CNN. The missile launch came only a day after Pyongyang and Washington agreed to resume nuclear talks, according to CNN.  

CNN reported that the US assessed that the missile was not fired from a submarine although the tested missile is designed to function as a submarine-launched ballistic missile (SLBM), the US official, who was familiar with the situation, said.

The missile was launched toward the East Sea, also known as the Sea of Japan, Wednesday morning, South Korea’s military said. While North Korea has launched from an underwater platform before, it is the first time it has done so since talks with President Trump, according to the CNN report.  

“Currently, our forces are maintaining readiness posture while watching related movements in preparation against additional launches,” South Korea’s Joint Chief of Staff said in a statement Wednesday.

Bolton’s recent statements on North Korea are in sharp contrast to Trump’s public statements indicating that previous talks with Kim have been highly productive in terms of the North Korean leader considering a reduction of his nuclear arsenal.    

Trump has asserted that Kim has “kept his word” when it comes to nuclear and missile testing. North Korea, however, has given little indication that it is ready to denuclearize, according to the report in the Washington Examiner.

Bolton dismissed the view that was cited by Trump that his strategy with Kim is working because North Korea has not conducted nuclear and long-range missile testing as of late. Such testing had at one time been a fairly regular practice.  According to a CNN report, Bolton said that the reason that Pyongyang has ceased these testing practices is that the technology is already in place.

“I am delighted to be here today. I’m also sure the leadership of North Korea is delighted I am here today in a private capacity, at least that’s what I’ve read,” Bolton said to his audience at the DC based think tank. “Perhaps they’ll be a little less delighted now that I can speak in unvarnished terms about the grave and growing threat that the north Korean nuclear weapons program poses to international peace and security.”

Earlier this month, Trump fired Bolton through a Tweet. Bolton, however, said that he offered the president his resignation the night before he learned of his firing. 

A veritable panoply of political pundits had opined that the sudden but not totally unexpected termination of Bolton would be interpreted as a gift of sorts to such rogue nations as Iran. Iran is an example of a nation that consistently viewed Bolton as a military hawk in the Trump administration and someone who had no problem advising the president to possibly initiate a military strike on them or even the imposition of harsher sanctions if Iran became way too bellicose in its posture towards America and the Western world.    

Bolton also raised the so-called “Libya model” for denuclearization again. When Bolton first mentioned it last year this model enraged Trump since the commander in chief believed that such a statement seemed to place a dark shadow on his diplomatic efforts with Kim. 

Describing the current situation with North Korea as a “classic standoff,” Bolton said the country’s leaders “want a piece of something that we should not be prepared to give them,” according to a CNN report. 

While Bolton voiced his foreign policy perspectives in a public fashion on Monday his comments were subdued when compared to those he uttered at a private event hosted by the Gatestone Institute in New York City earlier this month. The former US ambassador to the United Nations did not hold back on offering sharp criticism to the strategic approach Trump was taking to Iran, North Korea and Afghanistan.     

CNN reported that one attendee commented that, “Bolton didn’t have anything positive to say about Trump.”

Bolton said the now defunct idea of inviting the Taliban to Camp David was “disrespectful” to the victims of the September 11, 2001, terrorist attacks, but did not mention Trump by name, according to the attendee. 

As CNN previously reported, Bolton and Trump got into a heated argument over the President’s plan to host the Taliban leaders in the days before the 18th anniversary of the attacks, and Bolton did not acquiesce, according to two people who are familiar with what occurred said. 

One senior official confirmed this argument happened in the Oval Office and at the end of the meeting, the President asked Bolton for his resignation, according to the CNN report. 

On Wednesday, World Israel News reported that Trump and Iranian President Hassan Rouhani were on the verge of direct communication, but Rouhani pulled out at the last minute, according to a report by POLITICO, citing French sources.

According to the American news outlet, French President Emmanuel Macron, on the sidelines of the U.N. General Assembly gathering in New York last week, succeeded in getting Trump and Rouhani to agree on a four-point document designed to bring Iran and the U.S. back to the negotiating table, as was reported by World Israel News. 

The four points in the document reportedly included that Iran would “fully comply with its nuclear obligations and commitments and will accept a negotiation on a long-term framework for its nuclear activities.”

World Israel News reported that both parties were to “refrain from any aggression and will seek genuine peace and respect in the region through negotiations,” as was detailed in the report.

The agreement was also to include that the U.S. lift would “lift all the sanctions re-imposed since 2017,” said POLITICO, and that Iran would have the “full ability to export its oil and freely use its revenues.”

However, ultimately the Iranian and U.S. presidents did not meet because Rouhani insisted that Trump first declare that he would lift the U.S. sanctions, according to the officials cited by POLITICO.

As an alternative, Macron tried to arrange a phone call between the two leaders. The time reportedly had even been set: 9 p.m last Tuesday.

However, POLITICO reports, Rouhani refused to participate even in the phone conversation.

For its part, Tehran is blaming Trump for the failure of the French diplomatic effort, according to the World Israel News article. 

“By maintaining sanctions, Trump showed he is not determined to hold talks,” maintained Ali Rabiei, an Iranian government spokesman, cited by the Iranian Students’ News Agency (ISNA).

“The U.S. is directly responsible that the dialogue was not held…Washington should mend our distrust caused by its withdrawal from the Joint Comprehensive Plan of Action (JCPOA). But such an attempt is not witnessed in U.S. behavior,” the spokesman added.

The Joint Comprehensive Plan of Action is the official name of the Iran nuclear deal reached in 2015 between Tehran and six world powers including the U.S. Obama administration. Trump announced in May 2018 that Washington was withdrawing from the pact.

In a related development, World Israel News reported last week that  Abbas Nilforoushan, deputy commander of operations of the Iranian Revolutionary Guard Corps (IRGC), has said that Israel is not in a position to threaten Iran, and nothing will be left of Israel if they tried to launch an attack.

“Iran has encircled Israel from all four sides. Nothing will be left of Israel,” he said in an interview with Tasnim news agency.

“If Israel makes a strategic mistake, it has to collect bits and pieces of Tel Aviv from the lower depths of the Mediterranean Sea,” he added.

Nilforoushan asserted in the interview that no country can stand up to the Islamic Republic.

“Tehran’s enemies know that the they will not be in control of ending a war they might start against Iran,” he said.”If the enemies could have started a war against Iran, they would have done it.”

The IRGC commander also claims that Israel is incapable of entering a full-blown war because of its lack of strategic depth and internal divisions. (World Israel News)

Read more at: worldisraelnews.com

MTA Worker Had to Prove He is Jewish To Take Off on Rosh Hashanah

0
For four years the LIRR, managed by the MTA, together with local and state officials planned the ambitious South Fork Commuter Connection. Photo Credit: Shutterstock

Working for the MTA comes with many excellent perks due to their powerful union but try taking a Jewish holiday off.

By Henrietta Fishman 

A Jewish MTA conductor claims the agency is discriminating against him by telling him he must prove he’s Jewish in order to take off work for Rosh Hashanah, News 12 reported 

Officials with Transport Workers Local 100 told The Hill that the transit authority initially denied Benjamin Schaeffer, 22, permission to take the Jewish new year off. The MTA later said Schaeffer would be allowed to take Rosh Hashanah off, but he would need to document his observance of the holiday, the union officials added.

Schaeffer says he followed the MTA time-off policy and submitted paperwork for the day three weeks in advance but had his request denied. After contacting the Transport Workers Union, he says the MTA told him he could have the day off if he provided the documentation – but didn’t specify what documentation was needed, according to News 12.

Since this story came to light the MTA responded to local media with a statement from an  official spokesperson saying: “ We value and respect our employees’ religious beliefs and make every effort to accommodate requests for time off. This request was received after all leave slots for this day and job title had been distributed, but the supervisor involved made an exception for Mr. Schaeffer and granted him the day off. This issue has been reviewed by NYC Transit supervision and no documentation will be requested in this case of Mr. Schaeffer”

 Initially the union officials said an MTA supervisor told them there were “many employees who request to have days off for religious observance and are not granted due to the slots being full, and the high need for personnel. So in order to try to accommodate the employee’s and be fair, I am requesting documentation”, according to the Hill 

This smack of anti-Semitism, and is definitely anti-worker,” the union said in a statement to the Daily News. “What kind of railroad is MTA Chairman Pat Foye running?”

“This request was received after all leave slots for this day and job title had been distributed, but the supervisor involved made an exception for Mr. Schaeffer and granted him the day off. This issue has been reviewed by [New York City Transit Authority] supervision and it was confirmed that no documentation is necessary,” the MTA spokesperson concluded in statement to The Hill

Actor Robert DeNiro Uses “F Bomb” on CNN Program as He Curses Out Trump

0
Robert De Niro, his son, a movie producer named Jane Rosenthal and “immersive studio developer” Wildflower are behind a $400 million building project slated for Astoria, Queens. Photo Credit: Shutterstock

Brian Stelter, the host of the weekly program on CNN known as “Reliable Sources” tried to maintain his game face when confronted wit a foul mouthed guest in this week’s broadcast of the news/interview show.

Edited by: JV Staff

Iconic actor Robert DeNiro, who is known for his politically liberal views on a variety of matters minced no words while as a guest on Stelter’s program. The film and stage star has no problem spewing forth his venom on President Trump and even opted to release the F bomb in order to do so.

DeNiro not only launched the F bomb once, but he did it twice in a row while on the CNN Sunday morning show in response to Stelter’s observation that DeNiro had previously cursed Trump out on national television.

Stelter said, “When you say that, folks on Fox come after you. I remember the Tony’s when he got up there and cursed.”

De Niro shot back, “Fuck ’em. Fuck ’em.”

Stelter said in response, “This is cable, so it’s not an FCC violation, but it’s still a Sunday morning. I do wonder why you choose to go that way.”

De Niro said,  “In this country where this guy is like a gangster. He’s come along, and he’s said things, done things we say over and over again. This is terrible. We’re in a terrible situation. We’re in a terrible situation, and this guy just keeps going on and on without being stopped.”

According to a Breitbart report when asked about Trump being possibly impeached, DeNiro said,  “I think they have but no choice to have an impeachment inquiry. It has to happen. There’s no way around it.”

He added, ” “If it wasn’t for you, CNN, MSNBC and some other outlets, The New York Times, The Washington Post, I mean, where are we? This is a crazy world. What is going on? This guy is crazy. We’ve got to get him out.”

Stelter asked DeNiro to clarify his comments on Trump. The actor then said, “Possibly medically, too. I’m starting to think. I didn’t think that before, but now I actually — when I saw him out in front of the helicopter waiting to go somewhere and talking endlessly and sweating and sweating and not even —I said, this guy is not even aware of what he’s—he should at least ask somebody for a handkerchief or something and dry himself off. There is something very strange about that.” (Breitbart.com)