Injury of the corona mortis during vaginal tape insertion (TVT-Secur™ using the U-Approach)

We report a serious bleeding complication due to injury of the corona mortis following insertion of a transvaginal tape, TVT-Secur™ (Ethicon Women's Health, Sommerville, NJ, USA).

The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

[The Swiss approach for cardiac rehabilitation]

Structured cardiac rehabilitation goes back to the late 1960s also in Switzerland and in the beginning was only available in rehabilitation clinics. In 1972 the first ambulatory rehabilitation programs became available to patients in Zurich and Bern. In the following years, in addition to the increasing number of rehabilitation centers for inpatients, more and more ambulatory rehabilitation programs were developed, especially in the larger Midlands population area in German and French-speaking Switzerland. In 1985 the Swiss Working Group of Cardiac Rehabilitation (SAKR) was initiated as an official working group of the Swiss Society of Cardiology and one of its first tasks was to establish a list of the institutions for cardiac rehabilitation in Switzerland. At that time there were 42 rehabilitation programs for a population of approx. 6.5 million, 21 for inpatients and 21 ambulatory; however, 90% of the patients were in inpatient programs. In 1992 the SAKR group defined the quality criteria which were to be applied for official recognition of institutions for cardiac rehabilitation in Switzerland. Due to these criteria, plus the fact that an increasing number of rehabilitation clinics in the mountains had been closed down, the number of inpatient rehabilitation centers decreased from 21 to 11 between 1989 and 2011, whereas the number of ambulatory programs increased from 21 to 51. The ambulatory rehabilitation centers are partially organized by local medical groups; however, most have integrated their activities into the local hospitals. The trend shows a developing preference for ambulatory rehabilitation. More and more elderly, polymorbid patients, however, will still need care in inpatient programs.

Onychomycosis: The Current Approach to Diagnosis and Therapy, 2nd Edition

This new edition of a bestselling text illustrates the changes in attitudes towards fungal nail infections: previously attracting little interest, with a reputation for stubborn resistance to treatment, they have now reached the stage where there has been enormous recent scientific and medical progress, bringing with it a real possibility for a successful outcome of therapy for a growing population of patients. With this process has come the realization that there is now a clear choice of treatment determined by rational medical assessment. This book has been written by clinicians for clinicians, to provide a guide to the steps needed to identify and effectively manage the patient with onychomycosis. It is the first title in a new Series in Dermatological Therapy launched in conjunction with the Journal of Dermatological Therapy.

The transpedicular approach as an alternative route for intervertebral disc regeneration

STUDY DESIGN Descriptive anatomical study on ovine and human cadaveric lumbar spinal segments. OBJECTIVE To describe the alternative transpedicular approach to deliver therapeutic agents into intervertebral disc (IVD). SUMMARY OF BACKGROUND DATA The present delivery approach of therapeutic agents (growth factors/cells/hydrogels) within the IVD is through injection, via the annulus fibrosus (AF). However, it has recently been demonstrated that small needle puncture of the AF leads to further degeneration and disc herniation. In addition, the injected material has a high chance to be extruded through the AF injury. METHODS Lumbar ovine and human spinal segments were used. Under fluoroscopy, a 2-mm Kirschner wire was introduced in the caudal vertebra through the pedicle and the inferior endplate to the nucleus pulposus. Gross anatomy analysis and high-resolution peripheral quantitative computed tomography (HR-pQCT) were performed to assess the right position of the wire in pedicles. Discography and nucleotomy were performed using a 14G cannula insertion or a 2-mm arthroscopic shaver blade, respectively. Nucleoplasty was also performed with agarose gel/contrast agent and imaged with HR-pQCT. RESULTS Gross anatomy, fluoroscopy, and HR-pQCT images showed that the nucleus pulposus could be approached through the endplate via the pedicle without affecting the spinal canal and the neural foramina. The contrast agent was delivered into the IVD and nucleus pulposus was removed from the disc and filled with agarose gel. CONCLUSION This study describes how a transpedicular approach can be used as an alternative route to deliver therapeutic agents to the disc without disruption of the AF showing the potential use of this technique in preclinical research and highlighting its clinical relevance for IVD regeneration.

Minimising pain in farm animals: the 3S approach - 'Suppress, Substitute, Soothe'

Recently, the French National Institute for Agricultural Research appointed an expert committee to review the issue of pain in food-producing farm animals. To minimise pain, the authors developed a '3S' approach accounting for 'Suppress, Substitute and Soothe' by analogy with the '3Rs' approach of 'Reduction, Refinement and Replacement' applied in the context of animal experimentation. Thus, when addressing the matter of pain, the following steps and solutions could be assessed, in the light of their feasibility (technical constraints, logistics and regulations), acceptability (societal and financial aspects) and availability. The first solution is to suppress any source of pain that brings no obvious advantage to the animals or the producers, as well as sources of pain for which potential benefits are largely exceeded by the negative effects. For instance, tail docking of cattle has recently been eliminated. Genetic selection on the basis of resistance criteria (as e.g. for lameness in cattle and poultry) or reduction of undesirable traits (e.g. boar taint in pigs) may also reduce painful conditions or procedures. The second solution is to substitute a technique causing pain by another less-painful method. For example, if dehorning cattle is unavoidable, it is preferable to perform it at a very young age, cauterising the horn bud. Animal management and constraint systems should be designed to reduce the risk for injury and bruising. Lastly, in situations where pain is known to be present, because of animal management procedures such as dehorning or castration, or because of pathology, for example lameness, systemic or local pharmacological treatments should be used to soothe pain. These treatments should take into account the duration of pain, which, in the case of some management procedures or diseases, may persist for longer periods. The administration of pain medication may require the intervention of veterinarians, but exemptions exist where breeders are allowed to use local anaesthesia (e.g. castration and dehorning in Switzerland). Extension of such exemptions, national or European legislation on pain management, or the introduction of animal welfare codes by retailers into their meat products may help further developments. In addition, veterinarians and farmers should be given the necessary tools and information to take into account animal pain in their management decisions.