A diagnostically challenging case of ureterovaginal fistula after laparoscopic hysterectomy

A complicated case of iatrogenic ureterovaginal fistula in a 56-year-old woman after laparoscopic-assisted vaginal hysterectomy, which persisted after several attempts of repair including ureterocystoneostomy, is presented. Accurate radiologic work-up enabled us to identify a refluxing ureteral stump, which was not ligated at the time of ureterocystoneostomy, as the origin of urinary leakage. Surgical principles that should be adhered to when managing such complex cases to obtain successful long-lasting outcome are described.     

A new way of looking at Caesarean section births

AIMS: To implement the Robson Ten Group Classification System (TGCS) at the Royal Women's Hospital (RWH), Melbourne, in order to determine the main contributors to the rising Caesarean section (CS) rate. METHODS: The TGCS divides women into ten groups according to parity, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labour/delivery. The TGCS was applied retrospectively to the population of women who had a registered birth at the RWH between January 2005 and 31 December 2005. RESULTS: A total of 5833 women gave birth to 6011 babies during the study period. A total of 1651 women (28.3%) had a CS birth. The total CS rates ranged from 3.7% (group 3) to 100% (group 9). Women in groups 1 and 2 were the greatest contributors to the emergency CS rate, 4.2% and 4.9%, respectively. Women in group 5 were the single greatest contributor to both the elective CS rate and the total CS rate. CONCLUSIONS: The TGCS was successfully implemented at the RWH in 2005. The TGCS is ongoing, enabling monitoring of CS rates. The Robson TGCS demonstrates the need to focus on the care of women in groups 1, 2 and 5 in particular, if CS rates are to be reduced.     

Application of Saliva Inhibition to Detect Underlying Alloantibodies in Bombay Blood Group

IntroductionThe Bombay phenotype is a rare blood group determined by the absence of H antigens. Bombay individuals produce anti-H, a clinically significant antibody that react against all ABO blood group. Anti-H can mask underlying alloantibody during antibody investigation, a challenge in current transfusion practice. The aim of this article is to explore saliva inhibition, a novel method to detect underlying alloantibody in Bombay individuals.Case PresentationThe case is a 93-year-old female transfused with pre-donated autologous blood for a surgery. We determined anti-H subclass and thermal amplitude, secretor status, and optimal ratio of saliva and Bombay plasma. Plasma samples containing anti-H were spiked with anti-Fy(a) to determine the effectiveness of saliva inhibition in uncovering underlying alloantibodies.ResultsAnti-H was confirmed to be predominately IgM with broad thermal amplitude. Tube immediate spin (IS) showed stronger anti-H reactivity compared to column agglutination technology (CAT). Spiked anti-Fy(a) was successfully detected using saliva inhibition method.ConclusionTube IS appears more sensitive to anti-H. Saliva inhibition appears to be a promising method to detect underlying alloantibody in the plasma of Bombay phenotype individuals.     

Impact and management of dual relationships in metropolitan, regional and rural mental health practice

OBJECTIVE: To explore the extent and impact of professional boundary crossings in metropolitan, regional and rural mental health practice in Victoria and identify strategies mental health clinicians use to manage dual relationships. METHOD: Nine geographically located focus groups consisting of mental health clinicians: four focus groups in rural settings; three in a regional city and two in a metropolitan mental health service. A total of 52 participants were interviewed. RESULTS: Data revealed that professional boundaries were frequently breached in regional and rural settings and on occasions these breaches had a significantly negative impact. Factors influencing the impact were: longevity of the clinician's relationship with the community, expectations of the community, exposure to community 'gossip' and size of the community. Participants reported greater stress when the boundary crossing affected their partner and/or children. Clinicians used a range of proactive and reactive strategies, such as private telephone number, avoidance of social community activities, when faced with a potential boundary crossing. The feasibility of reactive strategies depended on the service configuration: availability of an alternative case manager, requirement for either patient or clinician to travel. The greater challenges faced by rural and regional clinicians were validated by metropolitan participants with rural experience and rural participants with metropolitan experience. CONCLUSIONS: No single strategy is used or appropriate for managing dual relationships in rural settings. Employers and professional bodies should provide clearer guidance for clinicians both in the management of dual relationships and the distinction between boundary crossings and boundary violation. Clinicians are clearly seeking to represent and protect the patients' interests; consideration should be given by consumer groups to steps that can be taken by patients to reciprocate.     

Effects of Tick-Control Interventions on Tick Abundance,Human Encounters with Ticks,and Incidence of Tickborne Diseases in Residential Neighborhoods,New York,USA

Tickborne diseases (TBDs) such as Lyme disease result in ≈500,000 diagnoses annually in the United States. Various methods can reduce the abundance of ticks at small spatial scales, but whether these methods lower incidence of TBDs is poorly understood. We conducted a randomized, replicated, fully crossed, placebo-controlled, masked experiment to test whether 2 environmentally safe interventions, the Tick Control System (TCS) and Met52 fungal spray, used separately or together, affected risk for and incidence of TBDs in humans and pets in 24 residential neighborhoods. All participating properties in a neighborhood received the same treatment. TCS was associated with fewer questing ticks and fewer ticks feeding on rodents. The interventions did not result in a significant difference in incidence of human TBDs but did significantly reduce incidence in pets. Our study is consistent with previous evidence suggesting that reducing tick abundance in residential areas might not reduce incidence of TBDs in humans.