Pelvic + Anatomy: A new interactive pelvic anatomy model. Prospective randomized control trial with first-year midwife residents.

Detailed knowledge of female pelvic floor anatomy is essential for midwifery and other professionals in obstetrics. Physical models have shown great potential for teaching anatomy and enhancing surgical skills. In this article, we introduce an innovative physical anatomy model called "Pelvic+" to teach anatomical relationships in the female pelvis. The Pelvic+ model's value was compared to a traditional lecture in 61 first-year midwifery students randomly allocated to either the Pelvic+ (n = 30) or a control group (n = 32). The primary outcome measure was a quiz comprised of 15 multiple choice questions on pelvic anatomy. Participants were assessed at baseline (Pre-Test), upon completion of the intervention (Post-Test1) and 4 months afterward (Post-Test2). Satisfaction with the approach was assessed at Post-Test1. Increase in knowledge was greater and the approach more accepted among resident midwives when Pelvic+ was used instead of standard lectures. Four months after the intervention, the improvement in knowledge was preserved in the Pelvic+ group. This randomized study demonstrates that the Pelvic+ simulator is more effective than classical learning for pelvic anatomy education, and offers a higher level of satisfaction among students during the educational process. Medical students training in obstetrics and gynecology, or any professional who specializes in the female pelvic floor might also benefit from incorporation of the Pelvic+ model into their training program.

Pharmacokinetics of Ferumoxytol in the Abdomen and Pelvis: A Dosing Study with 1.5- and 3.0-T MRI Relaxometry.

Background The off-label use of ferumoxytol (FE), an intravenous iron preparation for iron deficiency anemia, as a contrast agent for MRI is increasing; therefore, it is critical to understand its pharmacokinetics. Purpose To evaluate the pharmacokinetics of FE in the abdomen and pelvis, as assessed with quantitative 1.5- and 3.0-T MRI relaxometry. Materials and Methods R2*, an MRI technique used to estimate tissue iron content in the abdomen and pelvis, was performed at 1.5 and 3.0 T in 12 healthy volunteers between April 2015 and January 2016. Volunteers were randomly assigned to receive an FE dose of 2 mg per kilogram of body weight (FE2mg) or 4 mg/kg (FE4mg). MRI was repeated at 1.5 and 3.0 T for each volunteer at five time points: days 1, 2, 4, 7, and 30. A radiologist experienced in MRI relaxometry measured R2* in organs of the mononuclear phagocyte system (MPS) (ie, liver, spleen, and bone marrow), non-MPS anatomy (kidney, pancreas, and muscle), inguinal lymph nodes (LNs), and blood pool. A paired Student t test was used to compare changes in tissue R2*. Results Volunteers (six female; mean age, 44.3 years ± 12.2 [standard deviation]) received either FE2 mg (n = 5) or FE4 mg (n = 6). Overall R2* trend analysis was temporally significant (P < .001). Time to peak R2* in the MPS occurred on day 1 for FE2mg and between days 1 and 4 for FE4mg (P < .001 to P < .002). Time to peak R2* in non-MPS anatomy, LNs, and blood pool occurred on day 1 for both doses (P < .001 to P < .09). Except for the spleen (at 1.5 T) and liver, MPS R2* remained elevated through day 30 for both doses (P = .02 to P = .03). Except for the kidney and pancreas, non-MPS, LN, and blood pool R2* returned to baseline levels between days 2 and 4 at FE2mg (P = .06 to P = .49) and between days 4 and 7 at FE4mg (P = .06 to P = .63). There was no difference in R2* change between non-MPS and LN R2* at any time (range, 1-71 sec-1 vs 0-50 sec-1; P = .06 to P = .97). Conclusion The pharmacokinetics of ferumoxytol in lymph nodes are distinct from those in mononuclear phagocyte system (MPS) organs, parallel non-MPS anatomy, and the blood pool. © RSNA, 2019 Online supplemental material is available for this article.

Risk factors of low back pain and the relationship with sagittal vertebral alignment in Tanzania.

BACKGROUND: LBP is a common and serious problem affecting vast populations of the world. However, only few studies on LBP in sub-Saharan Africa have been conducted. Studies report that LBP and pelvic angle are interrelated, and African residents have a high pelvic tilt. The strategy to prevent LBP should focus on activities that promote holistic health. For that purpose, it is important to grasp the state of LBP and how it affects people's lifestyle in Tanzania to clarify the direction of implementation of physiotherapy treatment and reduce the incidences of LBP among adults. This study aimed to investigate the prevalence and presentation of low back pain (LBP) and the relationship between anthropometric measurements and LBP among people in Moshi city, Kilimanjaro region Tanzania. METHODS: Following signing consent forms, participants were given questionnaires regarding LBP and then grouped accordingly into either asymptomatic or symptomatic cohorts. Anthropometric measurements of participants' height, weight, curvature of the spine, and pelvic angle were obtained. RESULTS: A Mann-Whitney U test analysis showed a significant difference in pelvic angle, body mass index (BMI), and thoracic kyphosis angle between the asymptomatic group and the symptomatic group. No significant differences in lumbar lordosis angle or abdominal muscle strength were found between the two groups. CONCLUSIONS: A person with symptomatic LBP in Tanzania has a large anteversion of the pelvic tilt and a thoracic kyphotic posture. This study shows a relationship between sagittal spinal alignment and LBP in Tanzania, which could allow for prospective identification of subjects prone to developing LBP in the future.

'Draw your pelvis' test for assessing pelvic schema in people with Parkinson's disease: a validity and reliability study.

Aim: Body schema (i.e., the mental representation of the body and its parts) is important for cognitive and motor functions, with the pelvis constituting a core element in such schema. Although people with Parkinson's disease exhibit misperceptions and deficits in body schema, there are currently no published tools available for assessing pelvic schema in this population. This study aimed to develop and establish feasibility, reliability, and validity of a novel drawing test - 'Draw Your Pelvis' - for assessing pelvic schema in people with Parkinson's disease. Materials and methods: Twenty people with idiopathic Parkinson's disease (Hoehn &Yahr stages I-III; M age: 65.75 ± 10.13) volunteered and were asked to manually draw a picture of their pelvis. Drawings were assessed and scored by 13 blinded raters over two sessions. Intra- and inter-rater reliability and content and criterion validity were investigated. Results: The 'Draw Your Pelvis' test is shown to be feasible and quick to administer, with excellent inter-rater reliability for consistency (0.954-0.968) and absolute agreement (0.946-0.961). It also demonstrates good-excellent (0.614-0.950) intra-rater reliability, and is content valid. Conclusions: The 'Draw Your Pelvis' test holds potential for clinicians and researchers in assessing pelvic schema and its deficits in people with Parkinson's disease. In addition, this test could be used for investigating the effect of therapeutic interventions on body schema in this population. Future studies should explore this test in additional populations.

Standard reference values of the upper body posture in healthy young female adults in Germany: an observational study.

OBJECTIVE: Classifications of posture deviations are only possible compared with standard values. However, standard values have been published for healthy male adults but not for female adults. DESIGN: Observational study. SETTING: Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University Frankfurt/Main. PARTICIPANTS: 106healthy female volunteers (21-30 years old; 25.1±2.7 years) were included. Their body weight ranged from 46 to 106 kg (60.3±7.9 kg), the heights from 1.53 to 1.82 m (1.69±0.06 m) and the body mass index from 16.9 kg/m² to 37.6 kg/m² (21.1±2.6 kg/m²). OUTCOME MEASURES: A three-dimensional back scan was performed to measure the upper back posture in habitual standing. The tolerance ranges and CI were calculated. Group differences were tested by the Wilcoxon Mann-Whitney U test. RESULTS: In normal posture, the spinal column was marginally twisted to the left, and the vertebrae were marginally rotated to the right. The kyphosis angle is larger than the lumbar angle. Consequently, a more kyphotic posture is observed in the sagittal plane. The habitual posture is slightly scoliotic with a rotational component (scapular depression right, right scapula marginally more dorsally, high state of pelvic right, iliac right further rotated anteriorly). CONCLUSIONS: Healthy young women have an almost ideally balanced posture with minimal ventral body inclination and a marginal scoliotic deviation. Compared with young males, women show only marginal differences in the upper body posture. These values allow a comparison to other studies, both for control and patient data, and may serve as guideline in both clinical practice and scientific studies.

The earliest settlers of Mesoamerica date back to the late Pleistocene.

Preceramic human skeletal remains preserved in submerged caves near Tulum in the Mexican state of Quintana Roo, Mexico, reveal conflicting results regarding 14C dating. Here we use U-series techniques for dating a stalagmite overgrowing the pelvis of a human skeleton discovered in the submerged Chan Hol cave. The oldest closed system U/Th age comes from around 21 mm above the pelvis defining the terminus ante quem for the pelvis to 11311±370 y BP. However, the skeleton might be considerable older, probably as old as 13 ky BP as indicated by the speleothem stable isotope data. The Chan Hol individual confirms a late Pleistocene settling of Mesoamerica and represents one of the oldest human osteological remains in America.

New laparoscopic approach to the pudendal nerve for neuromodulation based on an anatomic study.

AIMS: The aim was to develop a new laparoscopic technique for placement of a pudendal lead. METHODS: Development of a direct, feasible and reliable minimal-invasive laparoscopic approach to the pudendal nerve (PN). Thirty-one embalmed human specimens were dissected for the relevant anatomic structures of the pelvis. Step-by-step documentation and analysis of the laparoscopic approach in order to locate the PN directly in its course around the medial part of the sacrospinous ligament and test this approach for feasibility. Landmarks for intraoperative navigation towards the PN as well as the possible position of an lead were selected and demonstrated. RESULTS: The visible medial umbilical fold, the intrapelvine part of the internal pudendal artery, the coccygeus muscle and the sacrospinous ligament are the main landmarks. The PN traverses the medial part of the sacrospinous ligament dorsally, medially to the internal pudendal artery. The medial part of the sacrospinous ligament has to be exposed in order to display the nerve. An lead can be placed ventrally on the nerve or around it, depending on the lead type or shape. CONCLUSIONS: A precise and reliable identification of the PN by means of laparoscopy is feasible with an easy four-step approach: (1) identification of the medial umbilical fold; (2) identification of the internal iliac artery; (3) identification of the internal pudendal artery and incision of the coccygeus muscle ('white line', arcuated line); and (4) exposition of the medial part of the sacrospinous ligament to display the PN.

Midwives' intrapartum monitoring process and management resulting in emergency referrals in Tanzania: a qualitative study.

BACKGROUND: In the United Republic of Tanzania, the maternal mortality ratio, and neonatal mortality rate have remained high for the last 10 years. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth. However, there have been delays in providing timely and necessary obstetric interventions, most likely due to lack of proper monitoring during labor. Yet, there has been little research concerning how midwives monitor the process of childbirth. Therefore, this study aimed to describe how midwives monitored and managed the process of childbirth to achieve early consulting and timely referral to obstetricians. METHODS: The design was qualitative and descriptive, using data from comprehensive semi-structured interviews of midwives. The interviews were conducted at one hospital and one health center in Dar es Salaam, Tanzania's largest city. Eleven participants were purposively recruited and interviewed about their experiences managing complicated intrapartum cases. After the interviews, data were analyzed using content analysis. RESULTS: Derived from the data were three activity phases: initial encounter, monitoring, and acting. During these phases, midwives noticed danger signs, identified problems, revised and confirmed initial problem identification, and organized for medical intervention or referral. The timing of taking action was different for each midwife and depended on the nature of the prolonged and obstructed labor case. CONCLUSIONS: For the majority of midwives, the processing of assessments and judgments was brief and without reflection, and only a few midwives took time to continue to monitor the labor after the initial identification of problems and before taking actions. To make a final judgment that the labor was becoming prolonged or obstructed, midwives should consider taking time to review and synthesize all their findings.

Primate pelvic anatomy and implications for birth.

The pelvis performs two major functions for terrestrial mammals. It provides somewhat rigid support for muscles engaged in locomotion and, for females, it serves as the birth canal. The result for many species, and especially for encephalized primates, is an 'obstetric dilemma' whereby the neonate often has to negotiate a tight squeeze in order to be born. On top of what was probably a baseline of challenging birth, locomotor changes in the evolution of bipedalism in the human lineage resulted in an even more complex birth process. Negotiation of the bipedal pelvis requires a series of rotations, the end of which has the infant emerging from the birth canal facing the opposite direction from the mother. This pattern, strikingly different from what is typically seen in monkeys and apes, places a premium on having assistance at delivery. Recently reported observations of births in monkeys and apes are used to compare the process in human and non-human primates, highlighting similarities and differences. These include presentation (face, occiput anterior or posterior), internal and external rotation, use of the hands by mothers and infants, reliance on assistance, and the developmental state of the neonate.

Surgical anatomy of the prostate in the era of radical robotic prostatectomy.

PURPOSE OF REVIEW: New insights in the anatomy of the prostate and the surrounding tissue evolve the technique of radical prostatectomy for the treatment of prostate cancer. RECENT FINDINGS: Regarding the course of the erectile nerves along the prostate, recent studies confirmed the presence of parasympathetic pro-erectile nerve fibers at the anterolateral aspect of the prostate. Another study of intraoperative electrostimulation of those nerves confirmed an increase in intracavernosal pressure by stimulations between the 1 and 3 o'clock position. Therefore, it is very likely that these anterior nerve fibers have an effect on erectile function. Regarding the urethral sphincter in the male, a study showed no attachment of the external sphincter to the levator ani muscle, probably resulting in an absence of a levator ani support to the continence mechanism. The male urinary sphincter seems to be in isolation responsible for urinary continence. SUMMARY: The nerve fibers at the anterolateral aspect of the prostate seem to participate in erectile function, which renders the concept of a high anterior release during nerve sparing beneficial. The isolated urinary sphincter mechanism results in the need to conserve as much urethral length as possible during radical prostatectomy to avoid urinary incontinence.

Reliability of bony anatomic landmark asymmetry assessment in the lumbopelvic region: application to osteopathic medical education.

The objective of this review is to establish the current state of knowledge on the reliability of clinical assessment of asymmetry in the lumbar spine and pelvis. To search the literature, the authors consulted the databases of MEDLINE, CINAHL, AMED, MANTIS, Academic Search Complete, and Web of Knowledge using different combinations of the following keywords: palpation, asymmetry, inter or intraexaminer reliability, tissue texture, assessment, and anatomic landmark. Of the 23 studies identified, 14 did not meet the inclusion criteria and were excluded. The quality and methods of studies investigating the reliability of bony anatomic landmark asymmetry assessment are variable. The κ statistic ranges without training for interexaminer reliability were as follows: anterior superior iliac spine (ASIS), -0.01 to 0.19; posterior superior iliac spine (PSIS), 0.04 to 0.15; inferior lateral angle, transverse plane (ILA-A/P), -0.03 to 0.11; inferior lateral angles, coronal plane (ILA-S/I), -0.01 to 0.08; sacral sulcus (SS), -0.4 to 0.37; lumbar spine transverse processes L1 through L5, 0.04 to 0.17. The corresponding ranges for intraexaminer reliability were higher for all associated landmarks: ASIS, 0.19 to 0.4; PSIS, 0.13 to 0.49; ILA-A/P, 0.1 to 0.2; ILA-S/I, 0.03 to 0.21; SS, 0.24 to 0.28; lumbar spine transverse processes L1 through L5, not applicable. Further research is needed to better understand the reliability of asymmetry assessment methods in manipulative medicine.

Laparoscopic endopelvic sacral implantation of a Brindley controller for recovery of bladder function in a paralyzed patient.

BACKGROUND: A number of techniques are being investigated to accomplish bladder control recovery in paralyzed patients using the neurostimulation, but currently, all techniques are based on the dorsal implantation of the electrodes using a laminectomy. METHODS: On 27 April 2006 we performed a laparoscopic implantation of a Finetech-Brindley bladder controller on the endopelvic sacral roots in a Th8 completely paralyzed woman who had previously undergone the removal of a Brindley controller due to an arachnoiditis after extrathecal implantation with intradural sacral deafferentation. RESULTS: We required about 3.5 h for the entire surgical procedure; no complications occurred and the patients went home on 5th postoperative day. The patient is now able to void empty her bladder and her rectum using the controller without further need for self-catheterisation. CONCLUSIONS: The presented new technique of laparoscopic implantation of electrodes on the endopelvic portion of the sacral nerve roots is an option to be considered in all paralyzed patients with further wish for electrical induced miction/defecation after previous deafferentation.

MRI-based registration of pelvic alignment affected by altered pelvic floor muscle characteristics.

BACKGROUND: Pelvic floor muscles have potential to influence relative pelvic alignment. Side asymmetry in pelvic floor muscle tension is claimed to induce pelvic malalignment. However, its nature and amplitude are not clear. There is a need for non-invasive and reliable assessment method. An intervention experiment of unilateral pelvic floor muscle activation on healthy females was performed using image data for intra-subject comparison of normal and altered configuration of bony pelvis. METHODS: Sequent magnetic resonance imaging of 14 females in supine position was performed with 1.5 T static body coil in coronal orientation. The intervention, surface functional electrostimulation, was applied to activate pelvic floor muscles on the right side. Spatial coordinates of 23 pelvic landmarks were localized in each subject and registered by specially designed magnetic resonance image data processing tool (MPT2006), where individual error calculation; data registration, analysis and 3D visualization were interfaced. FINDINGS: The effect of intervention was large (Cohen's d=1.34). We found significant differences in quantity (P<0.01) and quality (P=0.02) of normal and induced pelvic displacements. After pelvic floor muscle activation on the right side, pelvic structures shifted most frequently to the right side in ventro-caudal direction. The right femoral head, the right innominate and the coccyx showed the largest displacements. INTERPRETATION: The consequences arising from the capacity of pelvic floor muscles to displace pelvic bony structures are important to consider not only in management of malalignment syndrome but also in treatment of incontinence. The study has demonstrated benefits associated with processing of magnetic resonance image data within pelvic region with high localization and registration reliability.

An osteopathic approach to treating women with chronic pelvic pain.

Chronic pelvic pain is a common gynecologic complaint, affecting about 5% of American women. The differential diagnosis is broad, including many medical diseases, surgical indications, musculoskeletal problems, and somatic dysfunction. Women are more affected than men by pelvic pain because their bodies are subject to more changes. These changes include a cyclic hormonal milieu, major alterations in biomechanics during pregnancy, psychosocial stress, and other modifications during childrearing, and more adjustments during menopause. Both medical and surgical approaches to management exist, but integrative modes of therapy address the body-mind-spirit continuum. Osteopathic manipulative treatment is a valuable option for many affected women from childbirth to menopause.

Physiological asymmetry of trunk ranging and pelvis motility: an anatomo-functional study in 80 healthy subjects.

A key feature in physiotherapeutic treatment of patients with motion disturbances is the appropriate ranging of the trunk and pelvis motility. Eighty subjects randomly selected and free from known pathology of the muscular-skeletal and/or of the neurological system classed into four groups according to the age and the sex have been assessed, by using a new, simple and easy administrable tool. Our results demonstrate that the new measurement tool showed a very low intra- and inter-observer variability, that healthy subjects showed a more adduced and elevated right scapula if compared to the contralateral one and, as regard as the pelvic motion, a broader joint excursion in passive motion compared with active motion in the overall group, a broader joint excursion in young subjects compared with elderly ones, and a broader joint excursion in female subjects compared with males subjects. In conclusion our study allowed to identify a range of physiological asymmetry and pelvis motility. Such a range of physiological asymmetry might be useful as a reference for the physiotherapists.

Liposuction of the abdomen. An analysis of form.

This article presupposes that the surgeon has complete command of the process or craft of liposuction. This consideration of form does not presume to issue a commentary upon the ultimate fitness of the form; rather, form confines itself with shape. The final question that matters is, "has the surgeon used the craft to successfully alter the three-dimensional mass into an aesthetically pleasing end."

Three-dimensional ultrasound and magnetic resonance imaging of pelvic anatomy: potential for complications from minimally invasive procedures.

OBJECTIVE: Several new minimally invasive therapies have recently been popularized for both malignant and benign prostate disorders, including interstitial implantation of radioactive seeds and high-radiofrequency wires, cryoablation, transurethral thermotherapy, and laser prostatectomy. Complications can be incurred during the various procedures, often as a result of injury to adjacent anatomic structures. Some of the complications are inadvertent, whereas others are inherent in the particular treatment process. We hope to increase awareness and understanding of some of the potential complications. METHODS AND MATERIALS: Magnetic resonance (MR) and three-dimensional transrectal ultrasonography (TRUS) imaging were utilized to illustrate the relevant pelvic anatomy in, respectively, a healthy volunteer and four patients undergoing evaluation for prostate symptoms. In addition, data from the Visible Human dataset (the Visible Human Project is part of the National Library of Medicine 1986 Long-Range Plan) were used. RESULTS: The potential complications relating to urinary sphincter and anal sphincter control, sexual function, pelvic musculature, and pelvic nerve physiology could be explained on the basis of the MR and TRUS findings using cryoablation for illustrative purposes. CONCLUSION: A clear understanding of the relevant anatomy and physiology is essential for the physician to provide patient counseling preoperatively regarding anticipated sequelae and to avoid preventable intraoperative complications related to minimally invasive therapeutic procedures for the prostate.