“Triangle of safety”: anatomic considerations in transvaginal natural orifice surgery

Background

The introduction of transvaginal (TV) natural orifice transluminal endoscopic surgery (NOTES) brings the loss of traditionally used cutaneous landmarks for safe peritoneal access. This video describes the use of landmarks within the posterior vaginal fornix to define a “triangle of safety” wherein the peritoneal cavity can be accessed while minimizing the risk of injury to surrounding structures.

Methods

The triangle of safety is best identified in the following way. The cervix and posterior fornix are visualized. Then an imaginary clock located at the base of the cervix is envisioned. The superior two corners of the triangle are represented by the 4 and 8 o’clock positions on this imaginary clock. Sometimes the cervix needs to be grasped and elevated anteriorly so that the inferior apex of the triangle delineated by the center of the rectovaginal fold is better visualized.

Results

During hybrid TV NOTES, the rectovaginal pouch of Douglas is visualized from the umbilicus, and the vaginal port can then be safely passed through the center of the triangle. It is important that the vaginal port should be angled upward, aiming toward the umbilicus to avoid injury to the rectum. During pure TV NOTES, the incision is made with electrocautery from the 5 o’clock position to the 7 o’clock position within the triangle. The peritoneum is sharply entered, and the colpotomy is dilated with the surgeons’ fingers.

Conclusions

The triangle of safety defines a set of landmarks between the base of the cervix and the rectovaginal fold. It allows for a safe TV access for hybrid and pure TV NOTES while minimizing the risk of injury to surrounding structures.     

Acoustic analysis of voice in dysarthria following stroke

Although perceptual studies indicate the likelihood of voice disorders in persons with stroke, there have been few objective instrumental studies of voice dysfunction in dysarthria following stroke. This study reports automatic analysis of sustained vowel phonation for 61 speakers with stroke. The results show: (1) men with stroke and healthy elderly men exhibited an identical voice profile, and men with stroke had only one significantly larger noise parameter (SPI—soft phonation index) than young healthy men; and (2) women with stroke and healthy elderly women exhibited an identical voice profile, except that women with stroke exhibited a significantly higher SPI than healthy elderly women. Although there were no significant differences in smoothed pitch perturbation quotient (sPPQ) and SPI between healthy elderly women and healthy young women, women with stroke exhibited significantly larger sPPQ and SPI than healthy young women. It is suggested that studies on sub‐groups of the stroke population that use a combination of perceptual and acoustic analyses will better illuminate the voice dysfunction in dysarthria following stroke.     

The assessment of limb apraxia: Relationship between performances on single- and multiple-object tasks by left hemisphere damaged aphasic subjects

Two types of object manipulation tests, commonly advocated for the assessment of limb apraxia, were administered to 30 left hemisphere damaged aphasic (LHD) adults and 10 non-neurologically impaired control subjects. The tests were a multiple-object (MOT), requiring the manipulation of several related objects (e.g., lighting a candle when given a candle, a handle holder, and a match), and a single-object test (SOT) (e.g., lighting a match). Each of the subject's responses was assigned to one of six response categories: Standard (in which the response met all criteria for a faultless response) and five Nonstandard categories (Clumsy, Mislocation, Object Misuse, Perplexity, Omission). The results on comparing performances on the two tests showed that the SOT was “harder” than the MOT. Also, analyses of the relationship between MOT and SOT performances for the LHD subjects resulted in strong correlations between tests, loadings on the same two factors, and no evidence of double dissociations between the two tests for individual subjects. The two factors were interpreted to be a “conceptual/semantic” and a “motor execution” factor. The strong relationship and absence of double dissociations between response categories across the SOT and MOT suggest that both tasks are mediated by the same two neuropsychological processes. Clinical and theoretical implications of the findings are discussed.     

An unusual presentation of placental malaria: a single persisting nidus of sequestered parasites

Placental malaria caused by Plasmodium falciparum is a public health concern in tropical countries. Peripheral blood smears to detect placental malaria are often negative, and recrudescences are common during pregnancy. We performed placental histology on a series of first-time mothers delivering in an area endemic for P falciparum. A single nidus of malaria-infected erythrocytes was identified by placental histology in a single intervillous space from a woman who had no other evidence of peripheral or placental blood parasitemia. This finding suggests ring stage-infected erythrocytes sequester in vivo, or P falciparum can persist as a dormant blood stage form.     

Genomewide scans of red cell indices suggest linkage on chromosome 6q23

Background

The red cell indices quantify the size, number and oxygen‐carrying ability of erythrocytes. Although the genetic basis of many monogenic forms of anaemia is well understood, comparatively little is known about the genes responsible for variation in the red cell indices among healthy participants.

Objective

To identify quantitative trait loci (QTLs) responsible for normal variation in the red cell indices of 391 pairs of dizygotic twins who were measured longitudinally at 12, 14 and 16 years of age.

Results

Evidence suggesting linkage of red cell indices to haemoglobin concentration (LOD  = 3.03) and haematocrit (LOD  = 2.95) on chromosome 6q23, a region previously identified as possibly harbouring a QTL for haematocrit, was found. Evidence for linkage to several other regions of the genome, including chromosome 4q32 for red cell count and 7q for mean cell volume, was also found. In contrast, there was little evidence of linkage to the chromosomal regions containing the genes for erythropoietin (7q21) and its receptor (19p13.2), nor to the regions containing the genes for the haemoglobin α (16p13.3) and β chains (11p15.5).

Conclusion

Findings provide additional evidence for a QTL affecting haemoglobin and haematocrit on chromosome 6q23. In contrast, polymorphisms in the genes coding for erythropoietin, its receptor and the haemoglobin α and β chains do not appear to contribute substantially to variation in the red cell indices between healthy persons.The red cell indices describe the size, number and oxygen‐carrying capacity of erythrocytes. Haemoglobin concentration indicates the amount of oxygen‐carrying protein haemoglobin in a given volume of blood; red blood cell count (RBC), the concentration of erythrocytes; mean corpuscular volume (MCV), the average volume of each red cell; and haematocrit (HCT), the proportion of blood that consists of erythrocytes. Together, these indices assist in the differential diagnosis of anaemia and are risk factors for a number of clinical conditions. For example, a high haematocrit is associated with increased risk of cerebrovascular^1,2 and coronary artery diseases.¹Approximately 7% of the world''s population are carriers for different inherited disorders of haemoglobin, making them one of the most prevalent Mendelian diseases.³ Although the genetic basis of many of these haemoglobinopathies is well understood, comparatively little is known regarding the genetic causes of variation in the normal range of red cell values. Studies on twins have shown that a substantial proportion of the variation between persons is due to genetic factors with heritability estimates ranging from 20% to 96%.^4,5,6,7,8,9 A recent genomewide linkage study by Lin et al⁷ identified a locus on chromosome 6q23–24 linked to HCT, and a pleiotropic locus affecting haemoglobin and HCT on chromosome 9q.⁷ Interestingly, the authors found no evidence of linkage to regions containing the genes for the α and β haemoglobin chains (on chromosomes 16p13.3 and 11p15.5), nor erythropoietin and its receptor (on chromosomes 7q21 and 19p13.2), which have all been implicated in Mendelian forms of anaemia. The implication is that the quantitative trait loci (QTLs) responsible for normal variation in the red cell indices might differ from the loci which cause monogenic forms of anaemia.In a previous study, we reported that variation in the red cell indices was highly heritable, with genetic factors explaining between 61% and 96% of the phenotypic variance in our sample of adolescent twins.⁵ In this paper, we extend these results by performing a genomewide linkage scan of the 391 dizygotic twin pairs from that study. We measured the red cell indices of twins at 12, 14 and 16 years of age and performed univariate multipoint sib‐pair linkage analyses across the genome. Our study is the first to report linkage results for RBC and MCV, and will hopefully constitute the first stage in the identification and subsequent positional cloning of QTLs responsible for normal variation in the red cell indices.     

Nurses' satisfaction with medication administration point-of-care technology

Efforts to promote safe care prompted the development point-of-care technology, but successful adoption requires acceptance by nursing staff. To assess the satisfaction of nurses who use point-of-care technology that integrates nurse scanning of bar-coded medications with the patient's electronic medication administration record, the authors examined nurses' satisfaction with barcode/electronic medication administration record before and after introduction in an academic medical center.     

Using the Quality-Caring Model to organize patient care delivery

The organization of patient care in many acute care institutions lacks a foundation in nursing theory, yet preliminary evidence of the value of professional nursing care is increasing. The process and preliminary benefits of organizing patient care according to a professional practice model are presented using a collaborative partnership between an acute care organization and a school of nursing. A pilot implementation plan with formative and summative evaluation provided preliminary evidence used in project expansion.