Surgical Anatomy of the Nasofrontal Duct: Anatomical and Computed Tomographic Analysis

Objectives Although complete anatomical knowledge of the nasofrontal duct has been of great importance, little is known about it. The aim of this study is to examine the drainage site of the nasofrontal duct and to investigate the anatomical boundaries of the nasofrontal duct according to the drainage site. Study Design One hundred sagittally divided adult head specimens were analyzed by computed tomography and dissection under the surgical microscope. Methods Computed tomography scans of 50 adult cadaver heads were taken sagittally at 1‐mm intervals and coronally at 3‐mm intervals to find the nasofrontal duct. One hundred specimens, made up of sagittally divided adult cadaver heads, were dissected under the microscope to study the structure of the nasofrontal duct. Results We identified the anterior, posterior, medial, and lateral boundaries of the nasofrontal duct. In the most common type, the superior portion of the uncinate process formed the anterior border and the superior portion of the bulla ethmoidalis formed the posterior border of the nasofrontal duct. The conchal plate formed the medial border and the suprainfundibular plate formed the lateral border of the nasofrontal duct. Other variations are described in detail. Conclusions To widen the nasofrontal communication, removing the upper portion of the ground lamella of the ethmoid bulla, which is the posterior boundary of the nasofrontal duct, with cutting forceps seems to be a safe and easy method.     

Nephrology nursing: blurring the boundaries: the reality of expert practice

Background. Expertise in nursing has been widely studied; there have been no previous studies into what constitute expertise in nephrology (renal) nursing. This paper describes a ‘real‐world’ characteristic of expert nephrology nursing practice. Aims and objectives. This paper, which is abstracted from a larger study into the acquisition and exercise of nephrology nursing expertise, aims to explore the concept blurring the boundaries. Design. The study utilized grounded theory methodology and symbolic interactionism. Methods. The study took place in one renal unit in New South Wales. Sampling was purposive then theoretical; the sample consisting of six non‐expert and eleven expert nurses. Simultaneous data collection and analysis using participant observation, review of nursing documentation and semi‐structured interviews was undertaken. Results. The study revealed that only expert nephrology nurses ‘blurred the boundaries’ of professional nursing practice. They did this by moving intermittently and purposefully, for the benefit of particular patients, into medical domains in the areas of prescribing, dispensing and ordering of pathology tests. Non‐expert nurses did not cross these professional boundaries. Conclusions. Blurring the boundaries was a significant feature of expert nursing practice, and this study was the first to describe explicitly nursing boundaries as two distinct entities; that is, formal and informal. Relevance to clinical practice. There are some nephrology nurses who have sufficient knowledge and experience to prescribe some medications and to order certain investigations.     

Crossing boundaries,re-defining care: the role of the critical care outreach team

There is clear indication that both government and professional policy in the United Kingdom supports a radical change in the role of healthcare practitioners, with a move towards a patient-focused service delivered by clinical teams working effectively together. Recent health service imperatives driving the agenda for flexible clinical teams have occurred simultaneously with an increased public and political awareness of deficits in availability of critical care services. Against this policy backdrop, working across professional and organizational boundaries is fundamental to supporting quality service improvements. In the acute care sector, the development of critical care outreach teams is an innovation that seeks to challenge the traditional support available for sick ward patients. Activity data and observations from the first 6-month evaluation of two critical care outreach teams identify the need for clinical support and education offered by critical care practitioners to ward-based teams. The experiences from such flexible clinical teams provides a foundation from which to explore key issues for intradisciplinary and interdisciplinary working across clinical areas and organizational boundaries. Adopting innovative approaches to care delivery, such as critical care outreach teams, can enable clinical teams and NHS trusts to work together to improve the quality of care for acutely ill patients, support clinical practitioners working with this client group, and develop proactive service planning.     

The geography of patient safety: A topical analysis of sterility

Many studies on patient safety are geared towards prevention of adverse events by eliminating causes of error. In this article, I argue that patient safety research needs to widen its analytical scope and include causes of strength as well. This change of focus enables me to ask other questions, like why don't things go wrong more often? Or, what is the significance of time and space for patient safety? The focal point of this article is on the spatial dimension of patient safety. To gain insight into the ‘geography’ of patient safety and perform a topical analysis, I will focus on one specific kind of space (sterile space), one specific medical procedure (insertion of an intravenous line) and one specific medical ward (neonatology). Based on ethnographic data from research in the Netherlands, I demonstrate how spatial arrangements produce sterility and how sterility work produces spatial orders at the same time. Detailed analysis shows how a sterile line insertion involves the convergence of spatially distributed resources, relocations of the field of activity, an assemblage of an infrastructure of attention, a specific compositional order of materials, and the scaling down of one's degree of mobility. Sterility, I will argue, turns out to be a product of spatial orderings. Simultaneously, sterility work generates particular spatial orders, like open and restricted areas, by producing buffers and boundaries. However, the spatial order of sterility intersects with the spatial order of other lines of activity. Insight into the normative structure of these co-existing spatial orders turns out to be crucial for patient safety. By analyzing processes of spatial fine-tuning in everyday practice, it becomes possible to identify spatial competences and circumstances that enable staff members to provide safe health care. As such, a topical analysis offers an alternative perspective of patient safety, one that takes into account its spatial dimension.     

THE CHALLENGE OF WORKING WITH STAFF GROUPS IN THE CARING PROFESSIONS: THE IMPORTANCE OF THE 'TEAM DEVELOPMENT AND REFLECTIVE PRACTICE GROUP'

abstract    This paper highlights the importance of providing a regular space for teams of professionals, working in the mental health field and caring professions, to reflect on how the work impacts on the team dynamics and their own mental health. It explores the role of the group facilitator and how that role differs from working with patient and other groups. It considers the context of the current political environment within which mental health services operate and explores how this may impact on individual and team ego strength, leading to regression and reliance on primitive defence mechanisms as a means to coping and survival. Also considered is the issue of the challenges presented in working with teams where traits and features consistent with borderline personality disorder (DSM-4 Cluster B) manifest in the team. The authors propose a model called 'Team Development and Reflective Practice Groups', and suggest guidelines for providing an optimum facilitating environment for the professionals within these groups.     

Reliability of shoulder range of motion comparing a goniometer to a digital level

Abstract

The clinical use of digital levels, for joint measurement, may be a viable alternative to standard goniometry. The purpose of this study was to determine the intra- and intertester reliability of a construction grade digital level compared to the standard universal goniometer for measurements for active assisted shoulder range of motion (ROM). Two experienced physical therapists measured shoulder flexion, external rotation (ER), and internal rotation (IR) ROM bilaterally, on two different occasions, in 20 patients (9 males, 11 females, 18–79 years old) with unilateral shoulder pathology, using a goniometer and a digital level. Relative reliability was assessed by using intraclass correlation coefficients (ICC), and absolute reliability was assessed by using 95% limits of agreement (LOA). Intratester ICCs ranged from 0.91 to 0.99, and LOA ranged from 3° to 9° for measurements made with the goniometer and digital level. Intertester ICCs ranged from 0.31 to 0.95, and LOA ranged from 6° to 25°. For the comparison of goniometric vs. digital level ROM, ICCs ranged from 0.71 to 0.98. ER and IR ROM were 3–5° greater for the digital level than the goniometer (p < 0.01). Goniometric vs. digital level LOA ranged from 6° to 11° for shoulder flexion. Both measurement techniques had excellent intratester reliability, but for intertester reliability ICCs were 20% lower and LOA were 2.3 times higher than intratester values. Reliability estimates were similar between the digital level and the goniometer. However, because glenohumeral rotation was 3–5° greater for the digital level than the goniometer (systematic error), the two methods cannot be used interchangeably. On the basis of the average intratester LOA for the goniometer and the digital level, a change of 6–11° is needed to be certain that true change has occurred. For comparison of measures made by two different therapists, a change is of 15° is required to be certain a true change has occurred. A digital level can be used to reliably measure shoulder ROM but should not be used interchangeably with a standard goniometer.     

The Type II Error Probability of a Group Sequential Test of Efficacy and Futility,and Considerations for Power and Sample Size

For a clinical trial incorporating a group sequential test that allows early stopping for efficacy or futility (GSTEF), the primary hypothesis concerns efficacy. However, the type II error probability of the tests of efficacy is neither specified nor known. The type II error probability of a GSTEF is partitioned into the sum of its component type II error probabilities of futility and efficacy. This partitioning provides transparency, allowing researchers flexibility to set these component error probabilities directly and to know the impact on the total type II error probability and vice versa. This transparency and flexibility should improve the application of GSTEF to clinical trials.     

You Can’t Hide the Bridges

After witnessing a man commit suicide during residency, I struggled to reconcile the trauma itself, my own competence, and multiple boundary issues I was exploring as a newly minted doctor. My powerlessness in the face of inevitability challenged my sense of capability to fulfill the very calling that brought me into medicine in the beginning—to help fix important problems in the lives of my patients. In the aftermath, I chose to remain connected to the experience in the way I honor him still today.