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Pyeloplasty is one of the most common urological reconstructive interventions. Since the presentation of the first open pyeloplasty by Anderson and Hynes in 1949, the management of ureteropelvic junction obstruction has dramatically developed. The most immense progress was made in the 1990s with the introduction of laparoscopy. A multitude of new minimal surgical techniques have been introduced since then. In the last few years, the innovations were based on refinement of already-existing techniques and technology. With this aim, single-port surgery, three-dimensional vision for laparoscopy, robotic technology, and alternative techniques for creating the anastomosis-like fibrin glue have been introduced. This unsystematic review is timely, and the scientific interest is to present and discuss some of the latest advances in surgical techniques and different approaches for the intra- and post-operative management in pyeloplasty. To the best of our knowledge, this is the only review looking at the recent advances in urological surgical techniques for pyeloplasty during the last few years with a focus on new technology and surgical techniques.

Since 1970s quality has become a target for most organizations in the United States and most firms have spent millions of dollars on quality activities in order to reach defect-free productions [1]. This paper aims to discover how quality becomes a competitive advantage in different organizations. It includes some of the organizations that won Malcolm Baldrige Award in 2012 and shows what kind of criteria that made them qualified to win the award. The paper came up with a model called Performance Excellance shows the factor that lead to excellence performance in an organization. On the other hand, the paper aims to show what quality means from customers perspective. There is a survey conducted among 100 users of smartphones in order to discover what kind of features users prefer and is quality on of them or not. The results of the survey came up with the importance of quality from customers perspective. It shows that quality is one of the most important features users are looking for in a smartphone

Purpose: The Post-Ureteroscopic Lesion Scale (PULS) offers a simple grading system for the description of ureteral lesions after ureteroscopy. In this article, we present the results of a video-based multicenter evaluation of the inter-rater reliability of clinically important PULS grades 0-3. Methods: Video sequences at the end of ureteroscopy (final passage) were recorded for 100 consecutive patients at a single institution and assessed by experienced urologists (n = 20) and senior residents (n = 17) at 19 international centers. The cohort included only patients with lesions grades 0-3 (with grades 2 and 3 subsumed as 2 + since distinction is defined by an extravasation of contrast medium in fluoroscopy). The gradings were evaluated for inter-rater reliability and in terms of simplicity, validity, comprehensibility, reproducibility, and usefulness. Results: Overall, inter-rater reliability was high (Kendall's W = 0.69, p < 0.001) and was comparable between specialists (Kendall's W = 0.69, p < 0.001) and residents (Kendall's W = 0.71, p < 0.001). The matched ratings showed grade 0 in 43.0 % of patients and grades 1 or 2 + in 44.0 and 13.0 % of patients, respectively. Results of the questionnaires indicated a high degree of acceptance, with an overall rating of 1.76 (1.64-1.93 for different items, scale 1-6). Conclusions: Inter-rater reliability of the endoscopically assessable PULS was high among urologists with different levels of experience in different countries worldwide. The validated PULS system may be used for standardized reporting of ureteral lesions/injuries after ureteroscopy. In addition, PULS will enable more selective standardization of indications for postoperative DJ stenting based on the randomized controlled trials.

The robustness of Aumann’s seminal agreement theorem with respect to the common prior assumption is considered. More precisely, we show by means of an example that two Bayesian agents with almost identical prior beliefs can agree to completely disagree on their posterior beliefs. Besides, a more detailed agent model is introduced where posterior beliefs are formed on the basis of lexicographic prior beliefs. We then generalize Aumann’s agreement theorem to lexicographic prior beliefs and show that only a slight perturbation of the common lexicographic prior assumption at some-even arbitrarily deep-level is already compatible with common knowledge of completely opposed posterior beliefs. Hence, agents can actually agree to disagree even if there is only a slight deviation from the common prior assumption.

The impact of different fuels, gasoline, two ethanol–gasoline blends (E5, E85) and compressed natural gas (CNG), as well as lubricating oils on the aging behavior of Three-Way-Catalysts (TWCs) has been investigated with six state-of-the-art passenger cars over 40,000 km under real world driving conditions. For the study, all vehicles have been equipped with identical TWCs. During the investigation all relevant engine and vehicle operational parameters have been recorded. Exhaust gas measurements on a chassis dynamometer have been performed every 10,000 km. After 40,000 km, the surface of the TWCs has been analyzed by means of X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM) and energy dispersive X-ray spectroscopy (EDX). The investigations revealed significant P, Ca, Zn and partly Mg depositions on the wash coat layer of the catalyst inlet area, rapidly decreasing along the catalyst channels towards the outlet. The SEM images showed strongest ash depositions for the vehicles that had higher oil consumptions. Cracks and partly ablation of the wash coat at the inlet area of all TWC’s have been identified strongly differing from vehicle to vehicle. Strongest damages have been encountered on the catalysts of the vehicles fuelled by the ethanol blends. However, no emission deterioration of the vehicles could be determined over the New European Driving Cycle (NEDC) even after 40,000 km. In contrast, emission increase was ascertained over the more realistic Common Artemis Driving Cycle (CADC), which involves considerably higher space velocities of the exhaust gases through the catalysts. The vehicles using ethanol fuel blends, and having the severe damages on their wash coat layers showed the strongest emission deterioration. In contrary, vehicles with the thickest ash layer on the catalysts did not exhibit significant emission increase.

For clinical applications, the biological functions of DNA-binding proteins require that they interact with their target binding site with high affinity and specificity. Advances in randomized production and target-oriented selection of engineered artificial DNA-binding domains incited a rapidly expanding field of designer transcription factors (TFs). Engineered transcription factors are used in zinc-finger nuclease (ZFN) technology that allows targeted genome editing. Zinc-finger-binding domains fabricated by modular assembly display an unexpectedly high failure rate having either a lack of activity as ZFNs in human cells or activity at "off-target” binding sites on the human genome causing cell death. To address these shortcomings, we created new binding domains using a targeted modification strategy. We produced two SP1 mutants by exchanging amino acid residues in the alpha-helical region of the transcription factor SP1. We identified their best target binding sites and searched the NCBI HuRef genome for matches of the nine-base-pair consensus binding site of SP1 and the best binding sites of its mutants. Our research concludes that we can alter the binding preference of existing zinc-finger domains without altering its biological functionalities.

A model Pd-only three-way catalyst has been subjected to simulated driving conditions of natural gas and gasoline operation in an operando reactor cell for X-ray absorption spectroscopy that included alternated, but longer than real oscillations, rich and lean periods and a high temperature surge (850–900 °C). The X-ray absorption near edge structure (XANES) spectra indicated that metallic palladium is observed in the whole temperature range investigated (up to 900 °C) and irrespective of the air/fuel ratio. In both natural gas and gasoline cycles, the XANES data show that the PdO reduced in the rich periods cannot be restored in the lean periods. With this background, activity for methane abatement in the high temperature regime is greatly affected by the oxidation state of palladium rather than by the change of air/fuel ratio. In the case of propene oxidation, while Pd also remains predominantly in the reduced state, activity is dictated by the oxygen concentration in the feedstock. Comparison between the two hydrocarbons demonstrates that the oxidation state of Pd may be responsible for observed methane emissions under realistic operating circumstances. Moreover, the experiments demonstrate that reduced Pd may be continuously present during operation in agreement with observations on real catalytic converters. Although this may be the average oxidation state of Pd, more advanced probes are certainly necessary to capture variations of oxidation state under the fast oscillatory conditions needed to imitate real operation.

This paper discover the most administration security issues in Cloud Computing in term of trustworthy and gives the reader a big visualization of the concept of the Service Level Agreement in Cloud Computing and it’s some security issues. Finding a model that mostly guarantee that the data be saved secure within setting for factors which are data location, duration of keeping the data in cloud environment, trust between customer and provider, and procedure of formulating the SLA.

Acetone removal by evaporation has been proposed as a simple and cheap way to shift the equilibrium in the biocatalytic asymmetric synthesis of optically pure chiral amines, when 2-propylamine is used as the amine donor. However, dependent on the system properties, this may or may not be a suitable strategy. To avoid excessive laboratory work a model was used to assess the process feasibility. The results from the current study show that a simple model of the acetone removal dependence on temperature and sparging gas flowrate can be developed and fits the experimental data well. The model for acetone removal was then coupled to a simple model for biocatalyst kinetics and also for loss of substrate ketone by evaporation. The three models were used to simulate the effects of varying the critical process parameters and reaction equilibrium constants (K eq) as well as different substrate ketone volatilities (Henry's constant). The simulations were used to estimate the substrate losses and also the maximum yield that could be expected. The approach was seen to give a clear indication for which target amines the acetone evaporation strategy would be feasible and for which amines it would not. The study also shows the value of a modeling approach in conceptual process design prior to entering a biocatalyst screening or engineering program to assess the feasibility of a particular process strategy for a given target product.

Der kurzlich vorgestellte Freiburger Index fur Patientenzufriedenheit (FIPS) stellt ein neues Instrument zur Erfassung der behandlungsbezogenen Patientenzufriedenheit nach interventionellen und operativen Eingriffen dar. Der Fragebogen war zunachst an einem gemischten urologischen Krankengut psychometrisch gepruft worden. Die aktuelle Untersuchung beschreibt die Ergebnisse einer interdisziplinaren Validierung. Zusatzlich wird eine englischsprachige Version vorgestellt. Der Fragebogen wurde bei zwei weiteren Kohorten aus den Bereichen interventionelle Kardiologie (n = 120) und Allgemeinchirurgie (n = 127) eingesetzt. Die Auswertung beinhaltete eine umfassende methodisch-statistische Prufung einschlieslich Validierung an einem Vergleichsbogen (ZUF-8). Die psychometrische Evaluation zeigte gute Werte. In den untersuchten Stichproben ergaben sich keine fehlenden Werte und keine Deckeneffekte. Weiterhin konnten eine hohe Reliabilitat (Cronbachs α 0,82), die Eindimensionalitat, eine hinreichende Wertestreuung sowie die Validitat (hoher Zusammenhang zum ZUF-8, r = 0,65, p

Background Pre-transplant donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) have been associated with antibody-mediated rejection (AMR) and early kidney allograft loss. Uncertainties remain regarding the general applicability of these findings and the optimal induction therapy in DSA-positive patients. Methods Pre-transplant sera from 174 patients receiving a crossmatch-negative kidney transplant were retrospectively analysed for DSA using Luminex technology. DSA with mean-fluorescence intensity (MFI) values above 500 were considered positive. All recipients received basiliximab induction and tacrolimus-based maintenance immunosuppression. DSA were monitored post-transplantation in patients with pre-transplant DSA. Antibody results were correlated with the incidence of rejection and graft loss. Results In total, 61/174 patients had pre-transplant DSA. We found a strong correlation between the presence of DSA against class I and II HLA and DSA MFI greater than 10 000. Both DSA patterns independently predicted an increased risk of early AMR (odds ratio 4.24 and 4.75, respectively, P

The Cobb angle as an objective measure is used to determine the progression of deformity, and is the basis in the planning of conservative and surgical treatment. However, studies have shown that the Cobb angle has two limitations: an inter- and intraobserver variability of the measurement is approximately 3-5 degrees, and high variability regarding the definition of the end vertebra. Scoliosis is a three-dimensional (3D) pathology, and 3D pathologies cannot be completely assessed by two-dimensional (2D) methods, like 2D radiography. The objective of this study was to determine the intraobserver and interobserver reliability of end vertebra definition and Cobb angle measurement using X-rays and 3D computer tomography (CT) reconstructions in scoliotic spines.To assess interoberver variation the Cobb angle and the end vertebra were assessed by five observers in 55 patients using X-rays and 3D CT reconstructions. Definition of end vertebra and measurement of the Cobb angle was repeated two times with a three-week interval. Intraclass correlation coefficients (ICC) were used to determine the interobserver and intraobserver reliabilities. 95% prediction limits were provided for measurement errors.Intraclass correlation coefficient (ICC) showed excellent reliability for both methods. The measured Cobb angle was on average 9.2 degrees larger in the 3D CT group (72.8°, range 30-144) than on 2D radiography (63.6°, range 24-152).In scoliosis treatment it is very essential to determine the curve magnitude, which is larger in a 3D measurement compared to 2D radiography.

Study objective Sciatic nerve block (SNB) is commonly used as adjunct to femoralis nerve block (FNB) to achieve high-quality pain relief after total knee arthroplasty (TKA). However, this combination is associated with considerable muscle weakness, foot drop and surgically related nerve injuries may be masked. The purpose of this study was to assess whether low risk continuous intra-articular anesthetic drug instillation is an adequate alternative to SNB when adding to FNB after TKA. Design Retrospective investigational follow-up study. Setting University teaching hospital. Interdisciplinary postoperative anesthetic and orthopedic survey. Patients For this investigational analysis, 34 of 50 consecutive patients were available. Interventions All patients underwent primary unilateral TKA. Group A (18 patients) received a continuous intra-articular 0.33% ropivacaine (5 mL/h) instillation for the first 48 h postoperatively. In Group B (16 patients) a discontinuous SNB was used. Both groups were treated with a continuous FNB. Measurements Main endpoints were mean and maximum postoperative pain intensity levels for both anterior and posterior knee side, amount of postoperative administered opioid drugs, differences in functional outcome or hospital stay and rate of postoperative complications. Main results Group A showed higher pain intensity levels for the posterior knee side ( P ≤.042). Merely on the second postoperative day there were no differences within either study group. No differences were found regarding anterior knee pain. Group A showed a significant higher postoperative piritramid consumption ( P ≤.007). Length of hospital stay or postoperative functional outcome was not significant different. Postoperative complications were not related to anesthesia techniques. Conclusions SNB technique resulted in superior pain relief in comparison to continuous intra-articular local anesthetic drug instillation as adjunct to continuous FNB after TKA.

We reconsider Aumann' s seminal impossibility theorem that agents cannot agree to disagree in a topologically extended epistemic model. In such a framework, a possibility result on agreeing to disagree actually ensues. More precisely, agents with a common prior belief satisfying limit knowledge instead of common knowledge of their posterior beliefs may have distinct posterior beliefs. Since limit knowledge is defined as the limit of iterated mutual knowledge, agents can thus be said to limit-agree to disagree. Besides, an example is provided in which limit knowledge coincides with Rubinstein's (1989) notion of almost common knowledge, and the agents have almost common knowledge of posteriors yet distinct posterior beliefs. More generally, an epistemic-topological foundation for almost common knowledge is thus provided.

Objectives Thirty years after its introduction, extracorporeal shockwave lithotripsy (ESWL) is still first-line treatment for more than half of all urinary tract stones, but machines and treatment strategies have significantly developed over time. In this review, we summarise the latest knowledge about the clinically important aspects of ESWL. Methods We searched PubMed to identify relevant reports and the latest European Association of Urology guidelines, and standard urological textbooks were consulted. Results New technical developments include: Twin-head and tandem-pulse shock-wave generators; wide-focus, low-pressure systems; optimised coupling; and automated location and acoustic tracking systems. Indications have been refined, making possible the identification of patients in whom ESWL treatment is likely to fail. By lowering the shock-wave rate, improving coupling, applying abdominal compression, power ‘ramping’ and postoperative medical expulsion therapy, treatment protocols have been optimised. Conclusions Promising new technical developments are under development, with the potential to increase the stone-free rate after ESWL. For optimal results, the refined indications need to be respected and optimised treatment protocols should be applied.

Objectives To present the chronological development of the different positions described for percutaneous nephrolithotomy (PCNL), in an attempt to identify the reasons for their development and to highlight their specific advantages and disadvantages. Methods Previous reports were identified by a non-systematic search of Medline and Scopus. Results The classic prone position for PCNL was first described in 1976. The technique was gradually standardised and PCNL with the patient prone became the generally accepted standard approach. In the next 35 years many other positions were described, with the patient placed prone, lateral or supine in various modifications. Modifications of the classic prone position in the early 1990s aimed to provide the option of a simultaneous retrograde approach during the procedure. As PCNL became more popular the lateral position was first described in 1994, to allow the application of PCNL to patients who were unable to tolerate being prone because of their body habitus. The supine position for percutaneous access was originally described even before 1990, but become more popular after 2007 when the Galdakao modification was reported. Several other modifications of the supine position have been described, with the latest being the flank-free modified supine position, which allows the best exposure of the flank among the supine positions. Each position has its specific advantages and disadvantages. Conclusion Urologists who perform PCNL should be familiar with the differences in the positions and be able to use the method appropriate to each case.

BACKGROUND Kuntz et al recently introduced a new system for classifying spinal deformities. This classification of spinal deformity was developed from age-dependent deviations from the neutral upright spinal alignment. OBJECTIVE To determine the interobserver and intraobserver reliabilities of the new Kuntz et al system for classifying scoliosis. METHODS Fifty consecutive patients were evaluated. Three observers independently assigned a major structural curve, minor structural curve, curve type, apical vertebral rotation, spinal balance, and pelvic alignment to each curve following the guidelines described by Kuntz et al. Assignment of the curves was repeated 4 weeks later, with the curves presented in a different blinded order. The Kendall W and Holsti agreement coefficients were used to determine the interobserver and intraobserver agreement. RESULTS The intraobserver value of agreement for all parameters was 0.85 (range, 0.28-1.0), and the mean Kendall W coefficient was 0.89 (range, 0.5-0.97), demonstrating perfect reliability. The interobserver agreement averaged 0.7 (range, 0.251-1.0). The mean Kendall W coefficient was 0.67 (range, 0.19-1.0), demonstrating substantial reliability. The average time for classification of 1 curve was approximately 8.4 minutes. CONCLUSION The new Kuntz et al deformity classification system is comparable to the Lenke et al system in terms of reliability. However, the Kuntz et al classification system provides no recommendations for surgical interventions. It is more complex and time-consuming and therefore may be of limited value in daily clinical practice.

Introduction: Benign prostatic hyperplasia (BPH) and cataract formation are common in older people. Medical management of symptomatic BPH is often preferred to surgical treatment as surgery increases the risk of morbidities, whereas, surgery is the main form of treatment to restore sight in patient with cataract. The clinical treatment of BPH is either alpha-1 adrenergic antagonist alone or combination of alpha reductase inhibitor and alpha adrenergic receptor (AR) antagonist. There are four alpha-AR antagonists currently available to treat BPH. The uroselective alpha-blocker tamsulosin is the most commonly used drug among all. Studies showed that the majority of the patients who develop intraoperative floppy iris syndrome (IFIS) were on tamsulosin. Women are more likely to develop cataract than men and some recent studies showed that tamsulosin is effective in treating female lower urinary tract symptoms and thereby can cause IFIS during cataract surgery. Evidence Acquisition: We performed a critical review of the published articles and abstracts on association of IFIS with alpha-blockers and other medications as well as other medical conditions. Evidence Synthesis: Tamsulosin is the most common cause of formation of IFIS. However, not all patients given tamsulosin develop IFIS and cases have been reported without any tamsulosin treatment. Conclusion: Tamsulosin is a recognized cause to impede mydriasis and lead to IFIS during cataract surgery. Urologist should collaborate with their ophthalmology colleagues and general practitioner during prescribing tamsulosin in patients with history of cataract or waiting for planned cataract surgery. The increasing life expectancy and growth of older people will increase the number of men and women who suffer from lower urinary tract symptoms as well as cataract. Therefore, further research and studies are required to properly understand the relation of alpha blockers and IFIS.

Objectives: This study aims to assess the impact of a virtual reality trainer in improving percutaneous renal access skills of urological trainees. Methods: A total of 36 urology trainees participated in this prospective study. Initially, they were taken through the exercise of gaining access to the lower pole calyceal system and introducing a guidewire down the ureter. Trainees’ performance was then assessed by virtual reality-derived parameters of the simulator at baseline and after 2 h of training. Results: Participants who underwent training with the simulator demonstrated significant improvement in several parameters compared to their baseline performance. There was a statistically significant correlation between total time to perform the procedure and time of radiation exposure, radiation dose and correct calyx puncture (p < 0.01). Trainees needed a mean of 15.8 min from skin puncture to correct guidewire placement into the pelvicalyceal system before and 6.49 min following training. Conclusions: We found percutaneous renal access skills of trainees improve significantly on a number of parameters as a result of training on the PERC Mentor TM VR simulator. Such simulated training has the potential to decrease the risks and complications associated with the early stages of the learning curve when training for percutaneous renal access in patients.

Objectives: To evaluate whether the use of sheaths to access the ureter has increased after the introduction of new digital ureterorenoscopes in patients undergoing flexible ureteroscopy. Methods: 140 patients with kidney stones were randomised to be scoped with either an old-generation fibre-optic flexible ureteroscope (DUR-8, Elite, ACMI; distal tip diameter = 6.75 Fr) or a new-generation digital LCD flexible ureteroscope (Invisio D-URD flexible ureteroscope; distal tip diameter = 8.7 Fr). We recorded the necessity to use a sheath to access the ureter, sheath-related and postoperative complications, and whether or not a JJ stent was left behind. Results: 157 (80 fibre-optic and 77 digital) ureterorenoscopies were performed. Ureteral access sheaths were used significantly more frequently with digital scopes (p = 0.00174). Two patients in the digital scope group had a small distal ureteric perforation from the introducer sheath compared with none in the fibre-optic scope group. Conclusions: A statistically significant increase in sheath use was observed in the new-generation digital flexible ureteroscopy group. Despite the improvement in image quality, better durability and improved stone clearance, there are some potential drawbacks of these scopes. The increased distal tip diameter can result in increased use of ureteric access sheaths and this may increase morbidity and expense.

We calibrate and estimate a consumption-based asset pricing model with habit formation using limited participation consumption data. Based on survey data of a representative sample of American households, we distinguish between assetholder and non-assetholder consumption, as well as the standard aggregate consumption series commonly used in the CCAPM literature. We show that assetholder consumption outperforms non-assetholder and aggregate consumption data in explaining bond returns, bond yields, and the volatility of bond yields. We further show that the high volatility of assetholder consumption enables the model to explain the equity premium puzzle and the risk-free rate puzzle simultaneously for a reasonable value of relative risk aversion.

Tumors metastasizing to the glans penis are uncommon and a rare occurrence. The majority of the primary tumors are located in the pelvis and they arise from the genitourinary tract and rectum (>75%). We report a 61-year-old man with known metastatic (lymph nodes and maxilla) esophageal cancer who was treated with chemotherapy and referred to urology with phimosis for circumcision. He did not have any other urological or penile complaints. During circumcision the glans penis looked nodular and a biopsy was taken. The histological examination of the biopsy showed metastasis from esophageal primary adenocarcinoma. The case was discussed in a multi-disciplinary meeting and palliative radiotherapy was recommended and commenced.

Objective We provide a comprehensive overview of the main aspects of shock wave lithotripsy (SWL) for renal and ureteric stones. Evidence acquisition We reviewed current literature, concentrating on high-quality reviews in international journals. In addition, the latest European Association of Urology guidelines and standard textbooks were consulted. Evidence synthesis SWL can treat >90% of stones in adults and has revolutionized the treatment of urolithiasis. Despite the progress of minimally invasive endourologic procedures, SWL still contributes to >50% of all stone treatments worldwide. With modern machines, stone-free rates of the initial Dornier HM3 have not been reached again. Apart from stone size, multiple predictive outcome factors like stone composition, position, and renal anatomy have been identified, and indications have been refined. Interestingly, a growing number of nonurologic indications for SWL such as stimulating re-epithelization and improving myocardial function, have been reported recently. Furthermore, treatment protocols have been optimized by lowering shock wave rate, improving coupling, applying abdominal compression, power ramping, and postoperative medical expulsion therapy. New promising developments are twin-head and tandem-pulse shock wave generators. Automated localization and acoustic tracking and feedback systems have been developed with the potential to improve stone disintegration, to limit radiation, and to avoid overtreatment and complications. Conclusions SWL is a safe and well-established procedure that still plays an important role in the treatment of upper urinary tract stone disease. To achieve optimal results, the refined indications need to be respected and patients need to be carefully selected. Treatment protocols need to be optimized. Novel promising technical developments are upcoming, and there is growing interest in shock wave therapy from other specialties. SWL is a substantial part of urology that every urologist should learn to master during his or her training.

The incidence of ureteric obstruction after kidney transplantation is 3-12.4%, and the most common cause is ureteric stenosis. The standard treatment remains open surgical revision, but this is associated with significant morbidity and potential complications. By contrast, endourological approaches such as balloon dilatation of the ureter, ureterotomy or long-term ureteric stenting are minimally invasive treatment alternatives. Here we discuss the available minimally invasive treatment options to treat transplant ureteric strictures, with an emphasis on long-term stenting. Using an example patient, we describe the use of a long-term new-generation ureteric metal stent to treat a transplant ureter where a mesh wire stent had been placed 5 years previously. The mesh wire stent was heavily encrusted throughout, overgrown by urothelium and impossible to remove. Because the patient had several previous surgeries, we first considered endourological solutions. After re-canalising the ureter and mesh wire stent by a minimally invasive procedure, we inserted a Memokath® (PNN Medical, Kvistgaard, Denmark) through the embedded mesh wire stent. This illustrates a novel method for resolving the currently rare but existing problem of ureteric mesh wire stents becoming dysfunctional over time, and for treating complex transplant ureteric strictures.

We study the relationship between common knowledge and the sequence of iterated mutual knowledge from a topological point of view. It is shown that common knowledge is not equivalent to the limit of the sequence of iterated mutual knowledge. On that account the new epistemic operator limit knowledge is introduced and analyzed in the context of games. Indeed, an example is constructed where the behavioral implications of limit knowledge of rationality strictly refine those of common knowledge of rationality. More generally, it is then shown that limit knowledge of rationality is capable of characterizing any solution concept for some appropriate epistemic-topological conditions. Finally, some perspectives of a topologically enriched epistemic framework for games are discussed.

Some spine surgeons perform CT angiography for detailed planning of anterior access to the lumbar spine. However, the value of this imaging method and its influence on surgeons' decisions are unclear.We determined (1) the dose of radiation used in preoperative CT angiography and (2) whether CT angiography affects planning of anterior lumbar spine surgeries.We assessed preoperative CT angiograms of 28 patients undergoing anterior spine surgery. The level of aortic bifurcation, iliac vein confluence, course of the ascending lumbar vein, central sacral vessels, and any vascular variation were mapped. We determined the effective dose of radiation and recorded whether the preoperative CT angiography influenced surgical planning.We observed variations in the location of the aortic bifurcation and the iliac vein confluence. In 32% of patients, there were accessory renal arteries originating from the aorta; 7% had a rudimentary persistent left-sided caval vein. The findings did not change the plan for surgery in any patient. We detected high organ radiation dosages (mSv) for the stomach (63 mSv), liver (58 mSv), urinary bladder (47 mSv), and colon (46 mSv); other high exposure dosages involved the lungs, bone marrow, ovaries, and uterus.About one in 1919 men and one in 2971 women undergoing CT angiography therefore are expected to have colon cancer develop, and one in 2781 men and one in 2856 women are expected to have cancer of the urinary bladder develop. CT angiography is of low value for preoperative planning for anterior access to the lumbar spine and should be avoided to prevent radiation-induced damage.Level II, diagnostic study.

Study design Retrospective radiographic analysis. Objective To determine whether restoration and preservation of (a) disc height and (b) segmental lordosis differ between patients treated with circumferential lumbar fusion using a bone graft or a cage for anterior support. Summary of background data Restoration of disc height and lordosis is considered to be of crucial importance in circumferential fusion (CF). To determine whether restoration and preservation of disc height and segmental lordosis are dependent on the type of anterior support used, we compared the use of a cage with that of a bone graft in CF. Methods We retrospectively analyzed disc height and segmental lordosis in patients treated with primary lumbar monosegmental CF. The minimum period of follow-up was 9 months. A cage was used for anterior support in 23 patients and a bone graft in a further 23 patients. Disc height was determined on radiographs using an earlier introduced and validated distortion-compensated roentgen analysis, which was developed to compensate for distortion in central projection, off-center position, variation of stature, axial rotation, and lateral tilt of the spine. Results Disc height was restored in both groups but differences between preoperative and postoperative disc heights were significantly greater in the cage group (P=0.006). The cage also proved to be superior with regard to disc height preservation after follow-up (P=0.001). In addition, there was significantly less postoperative loss of segmental lordosis in the cage group (P=0.026). Conclusions The cage proved superior to the bone graft as anterior support in CF with respect to restoration/preservation of lordosis and disc height. However, no conclusions concerning clinical outcome or cost effectiveness can be drawn on the basis of this study.

Objectives. To determine the potential of eotaxin-3 as a diagnostic marker for active disease and genetic susceptibility factor for Churg-Strauss syndrome (CSS). Methods. A total of 37 patients with active, relapsed or inactive CSS, 123 healthy controls and 138 disease controls were studied. Clinical data were collected and serum levels of eotaxin-3 were determined. Ex vivo stability of eotaxin-3 in serum samples was tested. Furthermore, the association of single nucleotide polymorphisms (SNPs) in the eotaxin-3 gene with CSS was determined in 161 CSS patients and 124 healthy controls. Results. Serum eotaxin-3 was highly elevated in active CSS patients. Neither eosinophilic diseases nor other small-vessel vasculitides were associated with high serum eotaxin-3 levels. Receiver operating characteristic curve analysis determined a sensitivity and specificity of 87.5 and 98.6% at a cut-off level of 80 pg/ml. None of the tested SNPs within the eotaxin-3 gene influenced the susceptibility to develop CSS. Conclusions. Serum eotaxin-3 is a sensitive and specific marker for the diagnosis of active CSS suitable for routine clinical practice. Previously described SNPs in the eotaxin-3 gene do not predict the risk of developing CSS.

Objective: Government targets to reduce waiting times are putting enormous pressures on outpatient services. The implementation of an electronic care records service (CRS) at our hospital in 2008 has led to widespread press coverage of ensuing chaos in clinical administration. We wanted to know how this new electronic system impacted on our working patterns in outpatient clinics and – more specifically – on the time actually spent with the patients. Material & methods: This study was performed 4 and 12 months after implementation of CRS to assess its impact on the time distribution in clinic. Senior doctors were monitored with a stop clock during consultations. Timings for pre- and post-consultation administration, and the actual consultation with the patient were recorded. A total of 170 consultations were evaluated in this way. Results: The key findings were that the total time needed to spend on a urological outpatient of 16 minutes remains unchanged from the pre-CRS era, but a majority (57%) of this time is spent in administration on the computer without the patient involved. Conclusion: No more than 15 patients should be seen in a 4 hour outpatient clinic per doctor. This recommendation drawn up by BAUS before CRS remains still valid. Patient administration related to the consultation that has previously been done by administrative aides is now to be done by the doctors on the computer in the same consultation session. Intended to streamline patient pathways, this does reduce the quality interaction-time between doctor and patients significantly.

Introduction: The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases. Methods: All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively. Results: 42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5–60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases. Conclusion: Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures.

Multiple myeloma (MM) is considered a chronic and incurable disease due to its highly complex and heterogeneous molecular abnormalities. In recent years, integrating proteasome inhibitors and immunomodulatory drugs into MM frontline therapy has significantly improved treatment efficacy with a median overall survival (OS) being prolonged from 3-4 to 7 years. Despite this progress, patients refractory to the aforementioned agent classes display a median OS of only 9 months. Thus, the clinical necessity for developing novel therapeutic alternative approaches is self-evident. Methylation of N6-adenosine (m6A) is known to be important for diverse biological processes including gene expression control, translation of protein, and messenger RNA (mRNA) splicing. m6A regulatory enzymes consist of "writers" METTL3 and METTL14, "readers" YTHDF1 and YTHDF2, and "erasers" FTO and ALKBH5. However, the functions of m6A mRNA modification and the specific role of these enzymes in MM remain unknown. Here we report that METTL3, a key component of the m6A methyltransferase complex, is highly expressed in MM cell lines and in isolated patient's MM cells. In contrast, we found no significant differences in the expression of the m6A demethylases FTO and ALKBH5. Accordingly, compared to plasma cells from healthy donors, global PolyA+ RNA showed a significant increase in m6A content in patient's MM plasma cells. In MM cell lines, global m6A profiling by methylated RNA-immunoprecipitation sequencing revealed m6A peaks near the stop codon in mRNAs of multiple oncogenes including MAF and CCND1. Cross-linking immunoprecipitation showed that METTL3 bound to the m6A peak within MAF and CCND1 mRNA. Depletion of METTL3 by shRNA had little effect on global mRNA levels, but specifically reduced protein levels of c-Maf and Cyclin D1. Moreover, downregulation of METTL3 in several MM cell lines results in cell cycle arrest and apoptosis. Together, these results describe a role for METTL3 in promoting translation of a subset of oncogenes in MM and identify this enzyme as a potential therapeutic target for multiple myeloma. Disclosures No relevant conflicts of interest to declare.

A primary Echinococcus granulosus infection of the spine involving the vertebrae T8 and T9 of a 6-year-old child was treated elsewhere by thoracotomy, partial corporectomy, multiple laminectomies and uninstrumented fusion. Owing to inappropriate stabilization, severe deformity developed secondary to these surgeries. X-rays, CT and MRI scans of the spine revealed a severe thoracic kyphoscoliosis of more than 100 degrees (Fig. 1) and recurrence of Echinococcus granulosus infection. The intraspinal cyst formation was located between the stretched dural sac and the vertebral bodies of the kyphotic apex causing significant compression of the cord (Figs. 2, 3, 4). A progressive neurologic deficit was reported by the patient. At the time of referral, the patient was wheelchair bound and unable to walk by herself (Frankel Grade C). Standard antiinfectious therapy of Echinococcus granulosus requires a minimum treatment period of 3 months. This should be done before any surgical intervention because in case of a rupture of an active cyst, the delivered lipoprotein antigens of the parasite may cause a potentially lethal anaphylactic shock. Owing to the critical neurological status, we decided to perform surgery without full length preoperative antiinfectious therapy. Surgical treatment consisted in posterior vertebral column resection technique with an extensive bilateral costotransversectomy over three levels, re-decompression with cyst excision around the apex and multilevel corporectomy of the apex of the deformity. Stabilisation and correction of the spinal deformity were done by insertion of a vertebral body replacement cage anteriorly and posterior shortening by compression and by a multisegmental pedicle screw construct. After the surgery, antihelminthic therapy was continued. The patients neurological deficits resolved quickly: 4 weeks after surgery, the patient had Frankel Grade D and was ambulatory without any assistance. After an 18-month follow-up, the patient is free of recurrence of infection and free of neurologically deficits (Frankel E). This case demonstrates that inappropriate treatment--partial resection of the cyst, inappropriate anterior stabilization and posterior multilevel laminectomies without posterior stabilization--may lead to severe progressive kyphoscoliotic deformity and recurrence of infection, both leading to significant neurological injury presenting as a very difficult to treat pathology. Fig. 1 X-rays of the patient showing a kyhoscoliotic deformity. a ap view, b lateral view Fig. 2 CT reconstruction of the whole spine showing the apex of the deformity is located in the area of the previous surgeries Fig. 3 Sagittal CT-cut showing the bone bloc at the apex with a translation deformity Fig. 4 Sagittal T2-weighted MRI image showing the cystic formation at the apex.

Study Design Case report. Objective A retroperitoneal lymophocele is a very rare complication associated with anterior lumbar interbody fusion surgery. Summary of Background Data We report the diagnosis and management of 3 retroperitoneal lymphoceles, which occurred after anterior left retroperitoneal approaches for lumbar interbody fusion. Methods As the radiologic examinations revealed the lymphoceles in all 3 cases laparoscopic fenestration was performed. Results The patients had good recovery and no recurrence of the lymphoceles occurred. Conclusions If this rare complication occurs the primary intervention should be laparoscopic fenestration because of the high recurrence rate of other treatment modalities.

442 Background: Due to the suboptimal outcomes in recurrent superficial TCC over the last 30 years the search for new treatments continues. We report the first mid term results of a high risk cohort of heavily pretreated patients by a circulating device for intravesical thermochemotherapy.It is known that the effect of mitomycin increases at a temperature over 40 C. Methods: 58 patients with different failed methods of former intravesical therapy and recurrent TCC (21 intermediate risk and 37 high risk patients) were treated with the COMBAT device which facilitates irrigation of the bladder with mitomycin 40 mg at exactly 43 degree Celsius for 1 hour/6 courses weekly.Side effects were monitored prospectively and success of the treatment was controlled by ReTUR whenever possible and afterwards by 3 monthly cystoscopy and cytology. Results: 22 patients had dysuria during treatment and 9/58 suffered from hematuria but without intervention. In 6 cases urinary tract infection occured and 3 patients had allergic reaction. In one patient thermochemotherapy must be terminated due to pain and discomfort, no long term morbidity was recorded over the whole period. The FU was 14 month (3-29) for the entire cohort, 17 patients had a FU of over 2 years. One Patient had recurrent pTaGIII Tumor managed successfully by TUR. 2 patients underwent cystectomy because of invasive recurrence early after intravesical therapy, one patient developed bone metastasis 2 years after therapy without intravesical tumor. Conclusions: Thermochemotherapy with heated mitomycin is a well tolerated new option for patients with superficial TCC who are at high risk of recurrence or progression.The toxicity is acceptable and no long term morbidity was obeserved. The rate of cystectomies in this heavily pretreated group of patients including 18 BCG failures was very low with N= 2 respective 1,9%. Intravesical thermochemotherapy seems to be a new therapeutic bladder preserving option in high risk patients with superficial TCC. It is of note that thermochemotherapy has now been included in the European Guidelines.

Ovarian cancer continues to be one of the deadliest and lethal form of gynecological cancer affecting younger and older woman. Understanding various factors that could lead to ovarian cancer and how they are able to drive its progression, metastasis and survival might help in its treatment and prevention. This paper aims to review different risk factors both genetic and environmental that could lead to the development of ovarian cancer and their mechanism of action. The research methods used in this study follows the principles outlined by [1]. It is a comprehensive literature review on ovarian cancer risk factor. The role of genetics and environmental risk factors in ovarian carcinogenesis and their mechanism of action created a theoretical foundation of the paper. A new model is presented to encapsulate highly dynamic interaction between ovarian carcinogenesis and the mechanism of action of some associated risk factors. The contribution of the study is intended to review and summarize the theoretical and empirical knowledge that should inspire new discussions and directions for further research activity. The model highlights various factors that can trigger the development of ovarian cancer namely; TP53, BRCA genes, Cigarette smoke and Talc powder and how they are able to promote ovarian cancer. Various have been done about how mutation of certain genes and some environmental factors could lead to ovarian carcinogenesis. However, more research is needed to further understand how their mechanism of action. The content of this paper will be useful in devising a better screening, treatment and preventive measure towards the ovarian cancer. This study provides an exciting opportunity to advance our knowledge of ovarian cancer to efficiently aid medical practitioners and researchers to device better prevention and treatment plan to combat ovarian cancer.

Prion diseases are neurodegenerative diseases associated with the accumulation of a pathogenic isoform of the host-encoded prion protein. The cellular responses to prion infection are not well defined. By performing microarray analysis on cultured neuronal cells infected with prion strain 22L, in the group of up-regulated genes we observed predominantly genes of the cholesterol pathway. Increased transcript levels of at least nine enzymes involved in cholesterol synthesis, including the gene for the rate-limiting hydroxymethylglutaryl-CoA reductase, were detected. Up-regulation of cholesterogenic genes was attributable to a prion-dependent increase in the amount and activity of the sterol regulatory element-binding protein Srebp2, resulting in elevated levels of total and free cellular cholesterol. The up-regulation of cholesterol biosynthesis appeared to be a characteristic response of neurons to prion challenge, as cholesterogenic transcripts were also elevated in persistently infected GT-1 cells and prion-exposed primary hippocampal neurons but not in microglial cells and primary astrocytes. These results convincingly demonstrate that prion propagation not only depends on the availability of cholesterol but that neuronal cells themselves respond to prions with specific up-regulation of cholesterol biosynthesis.

The infectious agent in prion diseases consists of an aberrantly folded isoform of the cellular prion protein (PrPc), termed PrPSc, which accumulates in brains of affected individuals. Studies on prion-infected cultured cells indicate that cellular cholesterol homeostasis influences PrPSc propagation. Here, we demonstrate that the cellular PrPSc content decreases upon accumulation of cholesterol in late endosomes, as induced by NPC-1 knock-down or treatment with U18666A. PrPc trafficking, lipid raft association, and membrane turnover are not significantly altered by such treatments. Cellular PrPSc formation is not impaired, suggesting that PrPSc degradation is increased by intracellular cholesterol accumulation. Interestingly, PrPSc propagation in U18666A-treated cells was partially restored by overexpression of rab 9, which causes redistribution of cholesterol and possibly of PrPSc to the trans-Golgi network. Surprisingly, rab 9 overexpression itself reduced cellular PrPSc content, indicating that PrPSc production is highly sensitive to alterations in dynamics of vesicle trafficking. Electronic supplementary material The online version of this article (doi:10.1007/s00018-009-0158-4) contains supplementary material, which is available to authorized users.

The absence of uniformity, the use of different terminologies, and the diversity of methods used to translate numerical data into clinical outcomes have been described as potential problems when dealing with clinical knee scores for total knee arthroplasty (TKA). Gait analysis is believed to provide more objective parameters. The aim of the present study was to obtain information about the correlation between the outcome in terms of locomotion and the clinical knee score after TKA. Thirty consecutive patients awaiting TKA were involved in the study. One day prior to surgery and 3 months postoperatively, data pertaining to the Hospital for Special Surgery Score (HSS) and the Knee Society Score (KSS) (subgroups 'pain', 'knee', 'function' and 'total sum') were analyzed for correlations with kinematic and temporospatial parameters of gait analysis. At a significance-level of p

In this study, a state of the art passenger car natural gas engine was optimized for hydrogen–natural gas mixtures and high exhaust gas recirculation (EGR) rates in the major part of the engine map. The investigations involved stoichiometric combustion. With optimal combinations of spark timing and EGR rate, the achievements are efficiency increase with substantially lower engine-out NO x while total unburned hydrocarbons or CO-engine-out emissions are only modestly affected. The efficiency is increased by 3% in the low load and by more than 5% in the medium-load domain. Increasing hydrogen content of the fuel accelerates combustion leading to the efficiency improvements. Combustion analysis showed that the increasing burning rates mainly affected the initial combustion phase (duration for 5% mass-fraction burned). Nevertheless, increase of the hydrogen fraction in the fuel over a certain threshold did not result in any efficiency increase in the medium loads. Loss analysis identified high wall heat losses as the main reason. Dedicated combustion chamber design may be able to avoid these losses and lead to additional efficiency benefits. Well-to-wheel analysis revealed paths for the production of the fuel blends still having overall energy requirements slightly higher than a diesel benchmark vehicle but reducing by 7% overall green house gas emissions.

Because of air quality problems, the problem of CO 2 related greenhouse gas emissions and shortage of fossil fuels, many vehicles with gaseous fuels (CNG, biogas, hydrogen, etc.) are under research and development. Such vehicles have to prove that both their exhaust emissions and their overall system emissions (including running loss) remain below certain safety limits before they can be used in practice. This paper presents a cost-effective way of monitoring such system emissions from hydrogen or other gaseous fuel powered vehicles within an air-conditioned chassis dynamometer test cell, as commonly used for low ambient emission tests on gasoline vehicles. The only additional equipment needed is a low-concentration sensor for the gas of interest (e.g. hydrogen). The method is based on concentration measurements and a dynamic mass balance model. It is shown by a real experiment that very low emissions can be recorded. Additionally, error bounds and sensitivities on different parameters such as air exchange ratio are quantified.

Chimeric proteins joining the histone methyltransferase MLL with various fusion partners trigger distinctive lymphoid and myeloid leukemias. Here, we immunopurified proteins associated with ENL, a protein commonly fused to MLL. Identification of these ENL-associated proteins (EAPs) by mass spectrometry revealed enzymes with a known role in transcriptional elongation (RNA polymerase II C-terminal domain kinase [RNAPolII CTD] positive transcription elongation factor b [pTEFb]), and in chromatin modification (histone-H3 methyltransferase DOT1L) as well as other frequent MLL partners (AF4, AF5q31, and LAF4), and polycomb group members (RING1, CBX8, and BCoR). The composition of EAP was further verified by coimmunoprecipitation, 2-hybrid analysis, pull-down, and colocalization experiments. Purified EAP showed a histone H3 lysine 79–specific methylase activity, displayed a robust RNAPolII CTD kinase function, and counteracted the effect of the pTEFb inhibitor 5,6-dichloro-benzimidazole-riboside. In vivo, an ENL knock-down diminished genome-wide as well as gene-specific H3K79 dimethylation, reduced global run-on elongation, and inhibited transient transcriptional reporter activity. According to structure-function data, DOT1L recruitment was important for transformation by the MLL-ENL fusion derivative. These results suggest a function of ENL in histone modification and transcriptional elongation.

The objective of this study is to determine the intraobserver and interobserver reliability of end vertebra definition and Cobb angle measurement using printed and digital radiographs of 48 patients with scoliosis. The Cobb angle and the end vertebra were assessed by six observers in 48 patients with scoliosis using printed and digital radiographs. Definition of end vertebra and measurement of the Cobb angle was repeated three times with a 3 week interval. Intraclass correlation coefficients (ICC) were used to determine the interobserver and intraobserver reliabilities. 95% prediction limits for the errors in measurements are provided. For the Cobb angle a mean ICC of 0.97 was determined for intra- and interobserver reliability measurement of the printed radiographs. For the electronic radiographs a mean ICC value of 0.93 was determined for interobserver reliability and a mean ICC value of 0.96 for intraobserver reliability. Intraobserver ICC for definition of end vertebrae was 0.8 for both methods. Interobserver ICC was 0.83 for the manual and 0.74 in the digital method. One pitfall in angle measurement implies the Cobb method itself which measures in two dimensions. Until we develop a proper tri-dimensional measuring system an error is introduced. For the Cobb angle measurement the definition of end vertebrae introduces the main source of error. Digital radiography does not improve the measurement accuracy.