Removing the large uterus without morcellation - The Colpo-V incision for specimen extraction at hysterectomy.

BACKGROUND: Hysterectomy is the most commonly performed benign gynaecological surgery. Recently, the rates of minimally invasive hysterectomy have fallen due to the banning of mechanical morcellation techniques that rendered minimal invasive gynaecology surgeons unable to extract large uteri from the relatively small colpotomy incisions. AIMS: This study aims to share our experience in utilising Colpo-V incision to remove large uterine specimens transvaginally and report its success and complication rates to promote a minimal invasive approach in patients with large uteri without the need to perform large abdominal incisions or transabdominal morcellation. METHODS: This is a prospective case series study in which women with large uteri and|or narrow vaginal canal underwent total laparoscopic hysterectomy and a subsequent posterior vaginal wall incision (Colpo-V) to facilitate the intact extraction of the uterus through the vagina. Patients were seen in the clinic six weeks after the surgery for post-operative assessment and documentation of late complications. RESULTS: Seventeen women underwent the procedure, and the intact extraction of the specimen was successful in 16 out of the 17 cases (94%). No major complications were encountered during or after the procedure. CONCLUSION: Colpo-V incision is a simple and effective technique for the intact extraction of larger uterine specimens at hysterectomy.

Cultivating the Apprentice-Mentor Model for Minimally Invasive Gynaecology in the Era of Surgically Scarce Training: A Case Report of Laparoscopic Cornuostomy for Interstitial Ectopic Pregnancy by a Trainee.

Over the last few years, there is an apparent growing concern amongst O&G trainees of the inadequacy in exposure to minimally invasive gynaecology surgical training, which has been inadvertently compounded by the more stringent working hour regulations and disproportionately increasing number of trainees relative to surgical volume. Therefore, it is vitally important for trainees to maximise opportunities in the operating theatre and develop autonomy in carrying out more complex surgical procedures. This case report outlines the step-by-step approach of laparoscopic excision of a cornual ectopic pregnancy performed by a trainee under the supervision of a surgical mentor. This manuscript highlights key characteristic traits of a trainee that serve to foster surgical trust and simple but effective steps to foster surgical preparedness.

Service user, patient, survivor or client has the time come to return to 'patient'?

Recently, the Council of the UK Royal College of Psychiatrists agreed to use the term 'patient' as the preferred collective noun when referring to people accessing mental health services in its official documentation. Choices regarding terminology have the power to influence those who use such terms and here, David Christmas and Angela Sweeney debate the issue of whether such a decision is appropriate or whether we need to be more careful about the terms we use.

Uterine perfusion following laparoscopic clipping of uterine arteries at myomectomy.

Laparoscopic clipping of uterine arteries facilitates laparoscopic myomectomy with minimal blood loss. This paper shows the return to normal myometrial perfusion following this procedure with literary evidence of the safety and efficacy of this technique.

Is hysterectomy necessary for laparoscopic pelvic floor repair? A prospective study.

STUDY OBJECTIVE: To evaluate whether the addition of hysterectomy to laparoscopic pelvic floor repair has any impact on the short-term (perioperative) or long-term (prolapse outcome) effects of the surgery. DESIGN: A controlled prospective trial (Canadian Task Force classification II-1). SETTING: Private and public hospitals affiliated with a single institution. PATIENTS: A total of 64 patients with uterovaginal prolapse pelvic organ prolapse quantification system stage 2 to 4 had consent for laparoscopic pelvic floor repair from January 2005 through January 2006 (32 patients in each treatment arm). Patients self-selected to undergo hysterectomy in addition to their surgery. INTERVENTIONS: Patients were divided into group A (laparoscopic pelvic floor repair with hysterectomy) or group B (laparoscopic pelvic floor repair alone). All patients had laparoscopic pelvic floor repair in at least 1 compartment, whereas 52 patients had global pelvic floor prolapse requiring multicompartment repair. Burch colposuspension and/or additional vaginal procedures were performed at the discretion of the surgeon in each case. MEASUREMENTS AND MAIN RESULTS: Symptoms of prolapse and pelvic organ prolapse quantification system assessments were collected preoperatively, perioperatively, and at 6 weeks, 12 months, and 24 months postoperatively. Validated mental and physical health questionnaires (Short-Form Health Survey) were also completed at baseline, 6 weeks, and 12 months. No demographic differences occurred between the groups. Time of surgery was greater in group A (+35 minutes), as was estimated blood loss and inpatient stay, although the latter 2 results had no clinically significant impact. No difference between groups was detected in the rate of de novo postoperative symptoms. At 12 months, 4 (12.9%) patients in group A had recurrent prolapse as did 6 (21.4%) patients in group B. At 24 months these figures were 6 (22.2%) and 6 (21.4%), respectively. These differences were not statistically significant (p=.500 at 12 months and .746 at 24 months). In the group not having hysterectomy, 4 (14.3%) of 28 patients had cervical elongation or level-1 prolapse by the 12-month assessment. CONCLUSION: The addition of total laparoscopic hysterectomy to laparoscopic pelvic floor repair adds approximately 35 minutes to surgical time with no difference in the rate of perioperative or postoperative complications or prolapse outcome. Leaving the uterus in situ, however, is associated with a risk of cervical elongation potentially requiring further surgery. Laparoscopic pelvic floor repair is successful in 80% of patients at 2 years.

Sleep-disordered breathing before and after lung transplantation.

BACKGROUND: Sleep-disordered breathing (SDB) is common in patients with severe chronic respiratory failure, but there are no data describing the prevalence of SDB among patients listed for lung transplantation or the effect of transplantation on SDB. We sought to determine the prevalence and impact of SDB before and after lung transplantation. METHODS: We performed polysomnography (PSG) on 117 of 183 (64%) consecutive patients (64 males, 53 females) listed for lung transplantation between 1998 and 2001. SDB was defined as respiratory disturbance index (RDI) >or=10 or an awake oxygen saturation >90% and >or=10% of total sleep time (TST) with oxygen saturation (SaO2) or=10% of TST with SaO2 or=10. Eight of 32 had both >or=10% of TST with SaO2 or=10. Nine of 30 (30%) patients on oxygen and 1 of 7 on NIV had SDB. Post-transplant, SDB resolved in 6 of 11 patients with the condition, but 4 of 14 without previous SDB developed new SDB. SDB (treated or not) did not influence whether patients survived to transplant (p = 0.8), nor did a diagnosis of SBD prior to transplant influence post-transplant survival (p = 0.7). CONCLUSIONS: SDB is common before lung transplantation. Lung transplantation improves oxygenation, but new-onset SDB may occur after the procedure.

Modeling riverine nitrate export from an East-Central Illinois watershed using SWAT.

Reliable water quality models are needed to forecast the water quality consequences of different agricultural nutrient management scenarios. In this study, the Soil and Water Assessment Tool (SWAT), version 2000, was applied to simulate streamflow, riverine nitrate (NO(3)) export, crop yield, and watershed nitrogen (N) budgets in the upper Embarras River (UER) watershed in east-central Illinois, which has extensive maize-soybean cultivation, large N fertilizer input, and extensive tile drainage. During the calibration (1994-2002) and validation (1985-1993) periods, SWAT simulated monthly and annual stream flows with Nash-Sutcliffe coefficients (E) ranging from 0.67 to 0.94 and R(2) from 0.75 to 0.95. For monthly and annual NO(3) loads, E ranged from -0.16 to 0.45 and R(2) from 0.36 to 0.74. Annual maize and soybean yields were simulated with relative errors ranging from -10 to 6%. The model was then used to predict the changes in NO(3) output with N fertilizer application rates 10 to 50% lower than original application rates in UER. The calibrated SWAT predicted a 10 to 43% decrease in NO(3) export from UER and a 6 to 38% reduction in maize yield in response to the reduction in N fertilizer. The SWAT model markedly overestimated NO(3) export during major wet periods. Moreover, SWAT estimated soybean N fixation rates considerably greater than literature values, and some simulated changes in the N cycle in response to fertilizer reduction seemed to be unrealistic. Improving these aspects of SWAT could lead to more reliable predictions in the water quality outcomes of nutrient management practices in tile-drained watersheds.

Phosphorus transport pathways to streams in tile-drained agricultural watersheds.

Agriculture is a major nonpoint source of phosphorus (P) in the Midwest, but how surface runoff and tile drainage interact to affect temporal concentrations and fluxes of both dissolved and particulate P remains unclear. Our objective was to determine the dominant form of P in streams (dissolved or particulate) and identify the mode of transport of this P from fields to streams in tile-drained agricultural watersheds. We measured dissolved reactive P (DRP) and total P (TP) concentrations and loads in stream and tile water in the upper reaches of three watersheds in east-central Illinois (Embarras River, Lake Fork of the Kaskaskia River, and Big Ditch of the Sangamon River). For all 16 water year by watershed combinations examined, annual flow-weighted mean TP concentrations were >0.1 mg L(-1), and seven water year by watershed combinations exceeded 0.2 mg L(-1). Concentrations of DRP and particulate P (PP) increased with stream discharge; however, particulate P was the dominant form during overland runoff events, which greatly affected annual TP loads. Concentrations of DRP and PP in tiles increased with discharge, indicating tiles were a source of P to streams. Across watersheds, the greatest DRP concentrations (as high as 1.25 mg L(-1)) were associated with a precipitation event that followed widespread application of P fertilizer on frozen soils. Although eliminating this practice would reduce the potential for overland runoff of P, soil erosion and tile drainage would continue to be important transport pathways of P to streams in east-central Illinois.

Learning curve for hysteroscopic sterilisation: lessons from the first 80 cases.

The present report looks at the first 80 patients of Essure sterilisation performed by a surgeon with experience in operative hysteroscopy. The results show that the procedure is well tolerated under local anaesthesia with or without sedation, and that devices can be successfully placed in 90% of cases. Surgical time is reduced with increased experience, and successful placement increased by improving visibility within the endometrial cavity (cycle timing).

Nitrate flux in the Mississippi River.

Increased delivery of biologically available nitrogen to estuaries and coastal oceans in recent decades has been linked to eutrophication and seasonal hypoxia in the northern Gulf of Mexico and elsewhere. We have developed a model that accounts for 95% of annual variation in delivery of nitrate to the Gulf of Mexico by the Mississippi River in 1960-98. Retrospective analysis indicates that this nitrate flux could have been reduced by 33% if the use of nitrogen-containing fertilizer in the Mississippi River basin had been cut by 12%.

Estimated historical and current nitrogen balances for Illinois.

The Midwest has large riverine exports of nitrogen (N), with the largest flux per unit area to the Mississippi River system coming from Iowa and Illinois. We used historic and current data to estimate N inputs, outputs, and transformations for Illinois where human activity (principally agriculture and associated landscape drainage) have had a dominant impact. Presently, approximately 800,000 Mg of N is added each year as fertilizer and another 420,000 Mg is biologically fixed, primarily by soybean (Glycine max L. Merr.). These annual inputs are greater than exports in grain, which results in surplus N throughout the landscape. Rivers within the state export approximately 50% of this surplus N, mostly as nitrate, and the remainder appears to be denitrified or temporarily incorporated into the soil organic matter pool. The magnitude of N losses for 1880, 1910, 1950, and 1990 are compared. Initial cultivation of the prairies released large quantities of N (approximately 500,000 Mg N year(-1)), and resulted in riverine N transport during the late 19th century that appears to have been on the same order of magnitude as contemporary N losses. Riverine flux was estimated to have been at a minimum in about 1950, due to diminished net mineralization and low fertilizer inputs. Residual fertilizer N from corn (Zea mays L.), biological N fixed by soybean, short-circuiting of soil water through artificial drainage, and decreased cropping-system diversity appear to be the primary sources for current N export.

Determination of the quench velocity and rewetting temperature of hot surfaces: Formulation of a nonisothermal microscale hydrodynamic model.

A nonisothermal microscale model of the three-phase, solid-liquid-gas, contact zone is formulated in the context of rewetting phenomena. The model incorporates hydrodynamics, heat transfer, interfacial phenomena, and intermolecular long range forces, in a two-dimensional proximal region of the order of 1000 A in width and 100 A in thickness. The model comprises scaled mass, momentum, and energy balances, and their corresponding scaled boundary conditions. The small contact angles which are characteristic of rewetting situations facilitate the use of the lubrication approximation, and the dynamics of the liquid and gas phases is decoupled by applying the one-sided simplification. The microscale hydrodynamic model reflects the strong effect of the solid-liquid interactions on the film profile, and the attendant flow and thermal fields. Thinner films having smaller contact angles involve stronger solid-liquid attraction forces, and consequently they exhibit higher rewetting temperatures and lower evaporation and vapor recoil effects. Thermocapillary and evaporation and conduction effects are expressed by appropriate dimensionless numbers. A set of such numbers is defined in the context of the differential equations of the microscale model. This model covers the hydrodynamic aspect of rewetting phenomena, which are also controlled by thermodynamic and macroscale constraints. This calls for interfacing and appropriate combination between the microscale hydrodynamic model, thermodynamics, and other macroscale rewetting models, for the determination of rewetting temperatures and quench velocities of liquids on hot solid surfaces. This is addressed elsewhere, in subsequent papers that follow this work.

Autumnal changes of sulfur fractions and the ratio of organic sulfur to total nitrogen in leaves and adjacent bark of eastern cottonwood, white basswood and actinorhizal black alder.

Autumnal changes in organic-S, sulfate-S, total-S and the ratios of organic-S to total-N and sulfate-S to organic-S were followed in leaves and adjacent bark of actinorhizal (Frankia-nodulated) black alder (Alnus glutinosa (L.) Gaertn.) and eastern cottonwood (Populus deltoides Bartr. ex Marsh.) trees growing on a minespoil site high in extractable soil sulfate, and in black alder and white basswood (Tilia heterophylla Venten.) trees growing on a prairie-derived soil in Illinois. Organic-S concentrations decreased significantly (P < 0.05) during autumn only in foliage of trees growing on the prairie-derived soil where losses of leaf organic-S were 65% for black alder and 100% for white basswood. Leaf sulfate concentrations were relatively stable throughout autumn in white basswood growing on prairie-derived soil and in black alder at both sites. Sulfate-S concentrations in leaves were significantly (P < 0.05) higher in trees at the minespoil site than in trees growing in the prairie-derived soil (5.1 mg g(-1) for the minespoil site and 1.2 mg g(-1) for the prairie-derived soil), and in the non-actinorhizal species during late summer. During the autumn, the ratio of organic-S to total-N doubled in leaves of eastern cottonwood at the minespoil site, but in black alder and white basswood growing on the prarie-derived soil, it decreased by 60 and 74%, respectively. Organic-S concentrations in bark increased more during autumn in species unable to fix atmospheric N(2), than in black alder. The results suggest that patterns of autumnal translocation of leaf S can be site-dependent and that leaf S and leaf N are, at least in part, translocated independently in the fall. Black alder and eastern cottonwood seemed to incorporate sulfate-S readily into organic substances in leaves when grown in soils with a high sulfate content.