Search

Objective To characterize perioperative morbidity and mortality in adult patients with spina bifida undergoing laparotomy. Patients and Methods We retrospectively studied the postoperative complications of 59 operations of patients with spina bifida undergoing abdominal laparotomies for urologic indications at 3 institutions. We evaluated postoperative complications using the Clavien-Dindo classification scale. Results The overall complication rate was 91.5%. The most common complications were ileus, pressure ulcers, urinary tract infection, and wound infection. Over 40% of the patients developed a class 3 or 4 complication requiring subsequent surgery or intensive care unit admission. The hospital readmission rate was 42% and was correlated with higher-grade complications. On multivariable analysis, only older age was significantly associated with grade of complication. Conclusion These data demonstrate that adult patients with spina bifida comprise a unique population that faces an extremely high surgical risk even in centers of excellence. As patients with spina bifida live longer lives, thanks to modern medicine, there is a timely opportunity for research on perioperative management in these patients to improve postsurgical outcomes.

INTRODUCTION AND AIMS Videocystometrogram (VCMG) is used to assess patients with SUI. A common classification system of SUI is the Blaivas and Olsson classification. The position this grading is performed in has never been established. MATERIALS AND METHODS One hundred twenty-one women complaining of SUI refractory to conservative measures had video-urodynamic assessment prior to operative intervention. Grading of stored video SUI image traces was assessed as per Blaivas and Olsson criteria by two independent investigators whilst women were both lying and standing with bladder at maximum cystometric capacity. RESULTS Seventy-two (56.7%) patients' grading remained the same in both lying and standing positions. 49(40.5%) patients' grading altered on standing. twenty had non-demonstrable incontinence converted to demonstrable incontinence and 29 had demonstrable incontinence on lying that changed grading on standing; 22 of these by one grade and seven by two grades (from I to IIb). A Fisher's exact test demonstrated a statistically significant difference in the distribution of SUI grading between supine and standing positions (P

espanolEn este articulo analizo y cartografio algunos de los varios problemas conceptuales y filosoficos pertinentes a los discursos relacionados con la «descolonizacion epistemica». Estas discusiones ocurren en un amplio espectro de disciplinas y muchas veces implican ambiguedades o desacuerdos abiertos sobre puntos fundamentales. Este articulo ofrece una explicacion de porque la (des)colonizacion epistemica es un problema en primer lugar y pone en evidencia algunas de las diferencias claves entre varios enfoques distintos a la descolonizacion del conocimiento. La presente aclaracion, afirmo, es crucial para vincular proyectos de descolonizacion teorica a programas politicos concretos y para superar un enfoque prima facie para la descolonizacion del conocimiento. EnglishIn this paper I analyze and chart a number of the different conceptual and philosophical issues pertinent to discourses concerning ‘epistemic decolonization.’ Such discussions occur across a wide range of disciplines and often involve equivocations and/or overt disagreements about fundamental issues. This piece offers one account of why epistemic (de)colonization is a problem in the first place and brings to light some of the key differences between a number of different approaches to the decolonization of knowledge. The present clarification, I argue, is crucial to linking projects of theoretical decolonization to concrete political programs and to overcoming a prima facie approach to decolonizing knowledge. portuguesNo presente artigo, analisa-se um listado de diferentes conceitos e questoes filosoficas pertinentes para discursos relativos a descolonizacao epistemica. Tais discussoes perpassam um amplo espectro de disciplinas e com frequencia envolvem equivocos e/ou desacordos abertos sobre assuntos fundamentais. O artigo oferece uma narrativa sobre por que a descolonizacao epistemica e um problema e lanca luzes sobre diferencas fundamentais entre algumas abordagens acerca da descolonizacao do conhecimento. Argumenta-se que essa elucidacao e crucial para conectar projetos de descolonizacao teorica a programas politicos concretos e para superar uma abordagem prima facie acerca da descolonizacao do conhecimento.

The functional properties of human pediatric detrusor smooth muscle are poorly described, in contrast to those of adult tissue. Characterization is necessary for more informed management options of bladder dysfunction in children. We therefore compared the histological, contractile, intracellular Ca2+concentration responses and biomechanical properties of detrusor biopsy samples from pediatric (3–48 mo) and adults (40–60 yr) patients who had functionally normal bladders and were undergoing open surgery. The smooth muscle fraction of biopsies was isolated to measure proportions of smooth muscle and connective tissue (van Gieson stain); in muscle strips, isometric tension to contractile agonists or electrical field stimulation and their passive biomechanical properties; in isolated myocytes, intracellular Ca2+concentration responses to agonists. Pediatric detrusor tissue compared with adult tissue showed several differences: a smaller smooth muscle-to-connective tissue ratio, similar contractures to carbachol or α,β-methylene ATP when corrected for smooth muscle content, and similar intracellular Ca2+transients to carbachol, α,β-methylene ATP, raised K+concentration or caffeine, but smaller nerve-mediated contractions and greater passive stiffness with slower stress relaxation. In particular, there were significant atropine-resistant nerve-mediated contractions in pediatric samples. Detrusor smooth muscle from functionally normal pediatric human bladders is less contractile than that from adult bladders and exhibits greater passive stiffness. Reduced bladder contractile function is not due to reduced smooth muscle contractility but to greater connective tissue deposition and to functional denervation. Significant atropine resistance in pediatric detrusor, unlike in adult tissue, demonstrates a different profile of functional neurotransmitter activation. These data have implications for the management of pediatric bladder function by therapeutic approaches.

Objective To investigate sexual function and quality of life in adolescent and adult women with classic bladder exstrophy (BE). Materials and Methods A two-part observational cross-sectional study with a questionnaire arm and a retrospective case review arm was performed. The study was undertaken in a centre providing a tertiary referral gynaecology and urology service. Outcomes were sexual function and quality-of-life scores. Results A total of 44 patients with BE were identified from departmental databases and included in the study, of whom 28 (64%) completed postal questionnaires. Sexual function scores and quality-of-life visual analogue scales were significantly poorer compared with normative data. Conclusions Bladder exstrophy has a detrimental psychological impact on women. In future, methodical multidisciplinary paediatric follow-up research will help to identify predictors of better and worse adolescent and adult outcomes. Development and evaluation of cost-effective psychological interventions to target specific problems is also warranted.

Prior theories of individual behavior in recognizing public problems have centered on the role of policy entrepreneurs; institutional effects; information; and cultural, political, and social pressures. Our extension of these theories suggests that policy problem recognition is an attitudinal evaluation process. If the information is considered valid and the new attitude is negative in valence, then a policy problem is recognized. To test this theory, we use an embedded experiment in a national survey to measure the effect of persuasive messages on the concern for global warming. We find that the negativity of the message and the credibility of the source of the message both affect the level of increase in concern for global warming. Further, the impact of the message from the source is conditional based upon the recipient's ideology. This suggests that policy problem recognition is attitudinal and thus incorporates both analytical and affective components.

Complex congenital urological anomalies often necessitate ongoing clinical and surgical management as patients reach adulthood and beyond. However, adolescent and lifelong care of such conditions is a relatively new urological specialty, and approaches to transitional health care require further development. Thus, although literature relating to the use of such approaches in urology are lacking, we are able to draw upon experience of models from other specialties. Urological anomalies might complicate an individual's development, particularly during adolescence, which represents a time of rapid and considerable change in most aspects of life. During this period, increased independence and responsibility, necessitating a shift from parent-driven to patient-driven care, and the desire to develop important and intimate social relationships can affect a patient's ability to cope with, and manage, disease. These factors also influence the ability of health-care providers to deliver adequate treatment. In particular, consideration of the effect of a condition or its treatment on the patient's capacity to live a normal life is important. A multidisciplinary approach is essential to overcoming these issues. Furthermore, diagnostic and treatment registries, as well as an increase in the number of adult-focused urologists willing to participate in the transition of patients from paediatric to adult care, are needed to enable provision of optimal patient care for the future.

Objective To examine long-term quality-of-life, urinary continence and sexual function outcomes in patients diagnosed with bladder exstrophy (BE). Patients and Methods A total of 65 patients with BE and follow-up of at least 20 years were identified. After informed consent for inclusion in the study, the patients were asked to complete three validated questionnaires, the Short-Form 36 quality-of-life questionnaire (SF-36), the International Consultation on Incontinence Questionnaire (ICIQ) and the International Index of Erectile Function (IIEF), to assess quality of life, perceived urinary continence and sexual function. Results In all, 21 patients responded to the questionnaires, yielding a 32% response rate. High scores in each of the eight dimensions of the SF-36 reflected a positive perception of quality of life by respondents; calculated scores were compared with those of a normal control group. The only significant difference found between the groups was that the study population perceived their general health to be poorer than those in the control group. High scores on the ICIQ indicate high levels of subjective incontinence in patients, with scores ranging from 0 to 21. Reporting scores of 0 (continent), 12/21 patients perceived their continence to be normal, 9/21 patients had scores >2 (mild), with one patient scoring a 16, and 11 (severe incontinence), patients reported no identifiable leakage during normal activities. There was a 29% response rate for the IIEF (15 patients completed this). IIEF scores were broken down into five dimensions and mean scores were calculated. The mean scores showed mild to moderate dysfunction in each category, including overall satisfaction with sexual experience. Conclusions The patient-reported quality of life in patients with BE was normal in all dimensions, with the exception of perception of general health. Half of the patients reported normal continence and had no complaints of urinary leakage. Sexual function in males was significantly affected across all dimensions, with mild to moderate dysfunction.

The diagnosis and early management of genitourinary disorders in children is challenging for the child, parents and carers. There have been enormous developments in paediatric care medically and surgically and as a result many patients with complex anomalies reach adult life and have a normal desire for a good quality of life. Adolescence changes the challenges faced as anatomical growth may alter the surgical outcomes both functionally and cosmetically. Emotional and psychological development also creates important challenges that all those involved have to face. These patients need expert care and advice throughout adolescence and into adult life. This should be delivered by a multidisciplinary team that includes urology, gynaecology, nephrology, endocrinology and psychology. This creates a safe clinical and supportive environment for patients and their families.

The aim of this paper is to study the incidence and risk factors for genital prolapse in adult women with bladder exstrophy and to describe the long-term outcome of the Gore-Tex wrap procedure for genital prolapse. A retrospective observational study on adult women with classical bladder exstrophy in a tertiary referral centre for disorders of sex development, including complex urogenital anomalies. Medical notes were reviewed and a confidential postal questionnaire on urinary continence and symptoms of prolapse was carried out. Fifty-two women with bladder exstrophy and a mean age of 39 years (range 23 to 63) were identified, of whom 27 patients (52%) developed pelvic organ prolapse. Twenty-three out of 27 (85%) were treated surgically while only 4 patients were managed expectantly. Risk factors for prolapse included pregnancy in 10 (37%) patients and introitoplasty in 1 patient (4%). Of the 23 women treated surgically, 16 (70%) were treated using a Gore-Tex wrap, while 7 had other surgical procedures including colposuspension and hysterosacrocolpopexy. In the Gore-Tex wrap group, 12 out of 16 patients (75%) had had a successful result after the first repair compared with 2 out of the 7 patients (28%) in the group treated using other procedures. Mean follow-up was 8 years (range 1–15). One patient developed an infection after the procedure and another patient had Gore-Tex erosion. Prolapse is a common gynaecological complaint in adult women with bladder exstrophy and the majority will require treatment. At present the Gore-Tex wrap offers good results with a low rate of serious complications.

This essay provides a dimensional analysis of the various manners in which mathematics, phenomenology, and theology claim to make present or mediate infinity. Edmund Husserl's 1935 lecture, Philosophy and the Crisis of European Humanity, because engaged with each discipline to various degrees, will function as our primary, preparatory text. Husserl's discussion of the ideal objects of mathematics and the Greek attitude will call for further analysis of the relation between mathematics and infinity. Similarly, intentional infinities, insofar as related to transcendental phenomenology, will be compared to Jean-Luc Marion's distinct phenomenology of the icon. Next, the ways in which the infinite God is conceptualised by Husserl and Marion will be juxtaposed in order to demonstrate their disparate, theological thinking. Finally, the notion of multiple infinities will be analogically extended from set theory to the discursive wholes of mathematics, phenomenology, and theology in order to suggest a novel understanding of the role of the infinite within postmodern fundamental theology.

Models of the lower urinary tract are used to understand better the physiological and pathological functions of the tract and to gain insight into the relative importance of different components. The key requirement of a model is described, namely: to involve a continuous iteration with experiment; whereby experiments provide parameters and validation for components of the model, which is then used to generate hypotheses, which are tested experimentally. Different types of models are described: computational models that describe mathematically the whole urinary tract or components; physical models useful especially in testing medical devices; and tissue-engineered models. The purpose of modeling is first described in terms of the ability of models to predict the properties of the system of interest, using components that have a physiological interpretation, and to gain insight into the relative importance of different components. Examples are used to illustrate the use of modeling the urinary tract with reference to the different categories listed above. Neurourol. Urodynam. Neurourol. Urodynam. 30:692-699, 2011. © 2011 Wiley-Liss, Inc.

Ketamine has become increasingly recognized as a drug of recreational use. Individuals using significant amounts have developed symptoms including a small painful bladder, ureteric obstruction, papillary necrosis and hepatic dysfunction. The present paper examines the current literature on the relationship between ketamine use and these symptoms. Our own clinical experience and the data available clarify the causal relationship, and further data help to elucidate the mechanism of damage. On the basis of continued work and development with patients who are ketamine users we suggest an assessment and treatment regime that includes cessation of ketamine use and adequate analgesia to overcome symptoms. In conclusion, it is important for medical practitioners who encounter patients with these symptoms to ask about recreational drug use. Ketamine remains a safe and effective drug to use under appropriate medical supervision. Patients identified as suffering from this syndrome will need to be referred to a urological unit with an interest in the treatment of the condition.

Objective To collect information on clinical concerns relating to adolescent girls with disorders of sex development (DSD) during the process of transition from paediatric-to-adult clinical services. Subjects and methods This was a prospective audit of the clinical indications for referral and on-going clinical needs for all girls aged 12–20 years seen in a specialist DSD clinic over a 6-month period. Clinical needs were classified according to level of urgency using a simple ‘traffic light’ classification: green for low, amber for moderate, and red for high. Results Fifty girls were seen during the study period and all were referred from paediatric services. Patients may have had one or more indication(s) for referral to the adult clinic and these were: urology/gynaecology (70%), endocrinology (42%) and psychology (14%). The most common indication for on-going clinical input was psychology, with 46% of patients requiring monitoring and intervention. Of the 14 patients (28%) classified red suggesting they had an urgent clinical need, psychology was a major factor in all but one patient. Conclusion Clinicians working with adolescents with DSD need to develop a co-ordinated programme for transitional care that recognises the importance of psychological input within the multi-disciplinary team.

I have been asked to comment on Terry Moe's review essay "The Revolution in Presidential Studies." At the onset, I must say that I am not fully comfortable in this role. Accustomed to writing research reports on evidence of scientific findings, I often believe (rightly or wrongly) that I have something new and important to say. I am not accustomed to offering opinions about opinions. And, of course, that is what this dialogue is all about--opinions. Terry's review essay consists of opinions about the occurrence of a revolution in presidential studies, rooted in rational choice, formal methodologies, and, according to Terry, destined to expand with new theories and methodologies in the future. Terry applauds the use of rational choice in recent presidential studies, and argues that a revolution is a good thing for the evolution of current and future work. In my view, Terry's remarks should be taken seriously, because he has often been a precursor of future political science theory and research (see, e.g., Moe 1984, 1990; Moe and Howell 1999b). Indeed, many of the ideas Terry has espoused (sometimes borrowed from other disciplines) have also been used in my own work (e.g., see Wood 1988, 1990, 1991, 1992, 2010a, 2010b; Wood and Waterman 1991, 1993, 1994; Wood and Anderson 1993; Wood and Bohte 2004; Wood and Marchbanks 2007). Thus, I am an occasional user of the theories and methodologies endorsed by Terry. On the Applicability of Rational Choice in Presidential Studies Terry states that "while rational choice is destined to be the prime vehicle of theoretical progress in the near future (emphasis on "near"), it is not destined to drive out other approaches to presidential studies even in the short term--and it is likely to lose its dominance over the longer haul, both in presidential studies and in political science more generally, to competitors that are far more in keeping with the concerns of its critics" (Moe 2009, 703). This is a different message than we have heard from Terry in the past when he advocated rational choice (Moe 1993), and one I think many readers will find more compelling. Terry continues to send the message that strong theory and formalization are important. In my view, how one views this message should depend on how one views science in relation to our field. I came to political science and presidential studies along a different path than many others. My early training was in the physical sciences, not the social sciences. In the physical sciences, strong unifying theories are commonly applied to the study of physical phenomena. For example, the theory of quantum mechanics applies broadly to the behavior of electricity, magnetism, mechanical vibrations, sound waves, electromagnetic waves, radiation, superconductivity, and a plethora of other physical phenomena that occur at the particle level. Quantum mechanics displaced Newtonian mechanics, another strong unifying theory, as an explanation of some of these phenomena. Quantum mechanics also sometimes contradicts yet another strong unifying theory, Einstein's theory of general relativity. As a theory, quantum mechanics is heavily steeped in mathematical models, and even laws about the behavior of matter at the particle level. When I worked in the physical sciences, I found quantum theory very useful. Similarly, as a social scientist, I have always felt strongly that scientific advancement depends on strong theories such as those rooted in rational choice (see, e.g., Wood 2010a). However, my experience is not the only perspective that should be considered. Before and during the time I was in graduate school, I had a friend, Dr. Thomas Goka, who was a biomedical researcher studying the causes of cancer. He is now a dean at the University of Texas Graduate School of Biomedical Sciences. Tom is a medical doctor and also holds a doctorate in medical genetics. His methodology is not the application of formal mathematical models but experimentation. …

Past research attempting to explain the president's issue based liberalism has produced a muddled image. The most prominent work has been grounded in centrist theory, positing that presidents tailor their policy stances to mass preferences. Other work has also suggested that presidents cater to mass preferences, but only when their approval ratings are low or during elections. Still others find no relation between presidential issue liberalism and mass preferences, suggesting the importance of partisanship and pragmatism. We develop and validate a new measure of the president's issue based liberalism grounded in presidential rhetoric. We then test the centrist versus partisanship and pragmatism models of presidential liberalism using graphical and Box-Jenkins methods. Our graphical and statistical analyses firmly reject the centrist model and support an image of presidents as partisans whose public issue stances are sometimes moderated by pragmatic concerns. From the standpoint of democratic theory, our r...

Recent clinical trials have shown that combination therapy using an alpha-receptor antagonist and an antimuscarinic is more effective than either agent alone in improving quality of life and objective urodynamic variables in men with bladder outflow obstruction. There appear to be no negative effects on bladder function. The mode of action of this combination is unknown but presumed to be an antimuscarinic reduction in detrusor overactivity and the alpha-receptor antagonist reduced outflow tract resistance. We have shown with in vitro experiments that in smooth muscles influencing outflow tract resistance (prostate, trigone) there is a profound contractile synergy between adrenergic and muscarinic pathways. We propose the hypothesis that both arms of the combination therapy reduce contractile tone of the outflow tract and that their simultaneous attenuation has a disproportionately large effect on outflow tract resistance. Our data from trigone muscle suggest that adrenergic and muscarinic receptor activation increase the intracellular [Ca(2+)] but the adrenergic pathway also operates through Ca(2+)-sensitisation of the contractile apparatus, primarily through a PKC-dependent pathway.

Saber rattling is a prominent tool of the U.S. president's foreign policy leadership. Yet there has been no study of how presidential saber rattling affects international or domestic political outcomes. This study evaluates how presidential saber rattling affects U.S. economic behavior and performance. Theoretically, the study demonstrates that presidential rhetoric affects the risks that economic actors are willing to take, as well as the consequences of these resulting behaviors for U.S. economic performance. Using monthly time series running from January 1978 through January 2005, vector autoregression methods are applied to show that increased presidential saber rattling produces increased perceptions of negative economic news, declining consumer confidence, lower personal consumption expenditures, less demand for money, and slower economic growth. More broadly, the study demonstrates an important linkage between the president's two most important roles: foreign and economic policy leadership. The president's foreign policy pronouncements not only impact other nations, but also affect domestic economic outcomes.

Tissue engineering is a rapidly advancing technology that is shifting from the laboratory to urological practice. The review explores recent developments and considers the relationship to existing treatments.Different strategies to generate transplantable tissue grafts in vitro and harness host regenerative processes for integration of grafts and biomaterials in vivo are common themes in the recent literature. Highlights include dynamic cell culture to precondition grafts and the use of omental wrapping to promote vascularization. Emphasis on specific cell culture conditions is set to shift towards the monitoring of differentiation and functional outcome. The future might encompass the use of stem cells to overcome the issues of harvesting cells from diseased tissues. Improved understandings of scaffold and cell interactions are particularly important to advance graft development and outcome. Recent trials give some indication of clinical outcome for tissue-engineered treatments, but patient benefit could be difficult to interpret in salvage cases.Tissue engineering applications can be broken down into tissue- or organ-based approaches, only through examining these in clinical settings can potential success can be judged. Treatments must be appropriately evaluated for risk/benefit in comparison to existing treatments. This approach requires open and robust debate amongst clinicians and scientists.

Past research has proposed various macrolevel theories of issue definition and agenda setting. However, we propose a microlevel theory of issue definition rooted in how individuals process information. We theorize that people process information about policy issues through a filter that emphasizes past assessments, ideology, background, social cues, and the continuing intrusion of new information. Most of these factors lead individual issue definitions toward stability. However, the introduction of an information signal of appropriate magnitude and character can produce punctuations in issue definition by individuals through time. Since the macrolevel definition of an issue is a type of aggregation of individual definitions, understanding how individuals define issues becomes a precursor to understanding issue definition at the system level. In evaluating the theory, we develop and evaluate a survey to study the issue definition process for individuals across multiple issues, and for global warming specifically. The survey also includes two embedded experiments to demonstrate the potential for punctuation in the issue-definition process for individuals and the system.

The president's role as chief executive depends on the quality and tenure of political appointees who assist with the constitutional charge to “take care that the laws be faithfully executed.” This study explores the determinants of the duration of political appointee service. Using an agency theory framework, we propose that appointee tenure depends on financial incentives, executive-legislative conflict, solidary, and material benefits offered by the president, as well as implicit incentives that differ across presidential administrations. Using Office of Personnel Management records from January 1982 through August 2003, we employ multivariate survival analysis to confirm most aspects of the theory. The results imply that the most important determinants of political appointee tenure are financial and the difficulty of public administrative service. However, the president can affect exit propensities at the margins by manipulating rewards and implicit incentives that promote loyalty to public service and the administration.

Objective To develop consensus recommendations for index congenital urological cases seen in adulthood and to generate discussion among providers who treat these patients across the lifespan. This manuscript reviews the proceedings and recommendations of the 2015 American Urological Association Working Group on Urological Congenitalism. Methods Index cases were selected to highlight controversies in the management of different congenital patients in adulthood. Cases were presented and participants were randomized to groups to avoid clustering of individuals of similar background and experience. Expert panelists (representing backgrounds in pediatric and adult care of congenital patients) also discussed the cases. After that, a facilitated discussion was held with the entire group in an attempt to develop consensus recommendations for the questions raised in each case. Results Recommendations were generated related to management of pregnancy in young woman with bladder exstrophy and one with reflux nephropathy, as well as a young man with spina bifida with chronic kidney disease seeking undiversion. Conclusion Given the lack of long-term data for patients with congenital genitourinary diseases, management of complex urological disease in these patients can be difficult. Consensus discussion with urological providers across the spectrum of the life course of these patients may help provide clinical guidance.

Children with urinary tract disorders managed by teams, or individual pediatricians, urologists, nephrologists, gastroenterologists, neurologists, psychologists, and nurses at some point move from child-centered to adult-centered health systems. The actual physical change is referred to as the transfer whilst the process preceding this move constitutes transition of care. Our aims are twofold: to identify management and health-service problems related to children with congenital or acquired urological conditions who advance into adulthood and the clinical implications this has for long-term health and specialist care; and, to understand the issues facing both pediatric and adult-care clinicians and to develop a systems-approach model that meets the needs of young adults, their families and the clinicians working within adult services.Information was gleaned from presentations at an International Children's Continence Society meeting with collaboration from the International Continence Society, that discussed problems of transfer and transitioning such children. Several specialists attending this conference finalized this document identifying issues and highlighting ways to ease this transition and transfer of care for both patients and practitioners.The consensus was, urological patients with congenital or other lifelong care needs, are now entering adulthood in larger numbers than previously, necessitating new planning processes for tailored transfer of management. Adult teams must become familiar with new clinical problems in multiple organ systems and anticipate issues provoked by adolescence and physical growth. During this period of transitional care the clinician or team assists young patients to build attitudes, skills and understanding of processes needed to maximize function of their urinary tract-thus taking responsibility for their own healthcare needs. Preparation must also address, negotiating adult health care systems, psychosocial, educational or vocational issues, and mental wellbeing.Transitioning and transfer of children with major congenital anomalies to clinicians potentially unfamiliar with their conditions requires improved education both for receiving doctors and children's families. Early initiation of the transition process should allow the transference to take place at appropriate times based on the child's development, and environmental and financial factors. Neurourol. Urodynam. 36:811-819, 2017. © 2016 Wiley Periodicals, Inc.

Between a rock and a hard place About 1 in 2000 children are born with genitalia considered atypical enough to prompt medical investigation. Underlying causes include complex genetic and hormonal conditions as well as unexplained anatomical anomalies such as hypospadias. Paediatricians have previously stated that the determining factor in deciding to raise a child as a boy is the “size of the phallus.”1 2 Newborn penile size charts were used in the 1960s, and any child with a penis of stretched length less than 2.5 cm was likely to be assigned female regardless of the underlying diagnosis; feminising genital surgery usually followed.1 Gender assignment has become less simplistic but normalising surgery remains common. As a result, little is known about the physical, psychological, social, and sexual effects of untreated atypical genitalia associated with different diagnoses. It has been impossible to determine to what extent difficulties reported by adults are caused by the anatomical difference, other aspects of the diagnosis, the imperfect results of surgery, poor psychological care, or a combination of these factors. …

The initial goals of treatment of bladder exstrophy remain the preservation of renal function and obtaining urinary continence. If carried out in centres of excellence, surgery can achieve these relatively easy-to-measure goals in 70–80 % of children [1]. In adolescence and adulthood, once continence is secured, focus often shifts towards the cosmetic and functional outcome of the genitalia. The goals of additional procedures are to provide the external genitalia with an acceptable aesthetic appearance, to produce a functional vagina/penis for comfortable sexual intercourse, to retain sexually sensitive tissue for orgasm, and to preserve fertility potential. The results of genital surgery are difficult to assess in childhood, and pubertal growth can alter the final cosmetic and functional results of the initial reconstruction. Given that psychosexual development is only completed after puberty, problems may not become apparent until adolescence or early adult life. Now that patients are living independent long lives with bladder exstrophy following successful reconstruction, complex problems around pregnancy and delivery are evolving and becoming more commonplace.

Despite the massive scale of state-level budgeting, there currently exists no theoretically grounded and empirically sound examination of budgetary tradeoffs at this level of government. In order to provide such an examination, we extend a well-accepted approach to tradeoffs at the federal level in order to accommodate the unique intergovernmental aspects of state-level budgeting. We develop expectations that need for a good, ideology of state-level decisionmakers, and the relative amounts of federal grants received in each expenditure category all influence tradeoff decisions. We test these hypotheses in an analysis of budgetary decisions in all 50 states between 1971 and 1996.

Does the relative optimism of presidential remarks on the economy affect U.S. economic performance? We theorize that the relative optimism of presidential remarks should affect economic performance by altering consumer perceptions of the economic news and consumer sentiment, which in turn affect the risks consumers are willing to take in spending decisions. We measure the relative optimism of presidential remarks on the economy through content analysis of all public statements on the general economy and unemployment from January 1978 through April 2002. Controlling for current and past economic performance, we use vector autoregression analysis to show that presidential remarks significantly affect people's perceptions of the economic news, as well as their confidence about current and future economic conditions. Using simulation analyses, we also demonstrate that presidential rhetoric operating through these indirect channels can have substantial impacts on U.S. economic growth and unemployment. The larg...

This article describes the anatomy of the kidney and ureter. It begins with the embryological development and the mechanism for some congenital anomalies. The microscopic anatomy is described, as well as the gross anatomy of the kidneys, ureters and suprarenal (adrenal) glands including anatomical relations, arterial supply and venous and lymphatic drainage. Nerve supply and pain are also discussed.

The ileal conduit is held to be the safest and simplest form of urinary diversion. There are few reports about long-term problems after ileal conduit formation, especially intractable urinary incontinence in females. We reviewed long-term stomal complications in patients with an ileal conduit.Notes on 93 consecutive patients in whom an ileal conduit was created were reviewed. Information was collected on patient demographics, indications for an ileal conduit and long-term complications, in particular parastomal and incisional hernias, stomal retraction, stenosis or prolapse and the development of a redundant loop. Mean followup available was 63.4 months (range 1 to 434).A total of 33 males with a mean age of 60.1 years (range 2 to 78) and 60 females with a mean age of 48.2 years (range 4 to 79) underwent ileal conduit diversion. The main indications for an ileal conduit were intractable incontinence in 44 patients (47%), cancer in 31 (33%) and interstitial cystitis in 8 (9%). In male, continent female and incontinent female patients A parastomal hernia developed in 3 (9%), 2 (9.5%) and 12 (31%), an incisional hernia developed in 1 (3%), 1 (4.8%) and 2 (5%), stomal retraction developed in 0, 2 (9.5%) and 12 (31%), stomal stenosis developed in 0 (0%), 1 (4.8%) and 6 (15.4%), and a redundant loop developed in 0 (0%), 2 (9.5%) and 5 (12.8%), respectively. A total of 23 patients (24.7%) required further surgery for stomal problems with 13 (57%) requiring more than 1 reoperation, of whom 9 were incontinent females.An ileal conduit is associated with a stomal complication rate of 34.4% (61% in incontinent females and 18% in other patients) and a 4.3% incisional hernia rate. Reoperation is required for stomal complications in 24.7% of cases. Stomal complication rates and reoperation rates vary by sex and the indication for ileal conduit, and they are significantly higher for those performed for intractable urinary incontinence in females.

The two most important areas of leadership for any president are the economy and foreign policy. Presidential leadership in these two areas is mutually dependent, because foreign policy actions can affect U.S. macroeconomic performance (Wood and Durham 2004). However, this study focuses on direct efforts by the president to provide economic leadership through the use of rhetoric. Of course, the president has various tools of economic leadership. He can propose legislation that alters taxing or spending, thereby stimulating economic growth. The president can attempt to affect the cost of producer-consumer exchanges by changing regulatory policy. The president can also potentially affect interest rates and the money in consumers' pockets through nominations to the Federal Reserve Board. Yet, all of these tools are constrained by the need for cooperation from other political institutions. Additionally, there can be substantial lags in implementing these tools due to the fragmented nature of the American political system. In contrast, rhetorical leadership is a tool that the president can apply unilaterally without substantial impediment and delay. The president needs no permission from Congress or the bureaucracy to be a cheerleader for the economy or to tout ongoing programs. The president is an authoritative source of information about the current and future state of the economy with near continuous access to the media and public. As such, presidential rhetoric is a cue for businesses and consumers making decisions on investment and spending. While the president may be tangential to these decisions, the president's economic rhetoric affects the tone under which consumers and businesses make decisions (Wood, Owens, and Durham 2004). Presidents have strong incentives to use economic rhetoric in their public appearances. Since the Great Depression there has been an expectation that the national government is responsible for the economy. The Employment Act of 1946 institutionalized an activist role for the president, formally charging the chief executive with promoting "maximum employment, production, and purchasing power" (Public Law 79-304). From this point forward, presidents were required to make an annual economic report to Congress detailing the current and future state of the economy, as well as the administration's plans and recommendations for promoting these goals. The mandate for the president to promote a sound economy was reinforced in 1978 through the Humphrey-Hawkins Act, which required the president to establish targets for inflation and unemployment. (1) Presidents usually find it valuable to publicize their efforts on the economy to give a perception of fulfilling these legal mandates. Additionally, presidents attend to the economy in their public remarks to appear in charge of an issue critical to presidential power and success. Americans hold the president accountable for U.S. economic performance. There are numerous studies showing that macroeconomic performance is a strong determinant of the president's job approval rating (e.g., see Mueller 1970; Monroe 1978; MacKuen 1983; MacKuen, Erikson, and Stimson 1992; Ostrom and Smith 1993; Clark and Stewart 1994; Edwards, Mitchell, and Welch 1995; Wood 2000). Most political actors believe strongly that presidential approval is important to presidential success in Congress and credibility in other areas such as foreign policy (e.g., see Edwards 2003, chapter 1). Therefore, presidents wanting to maintain public approval need to appear to be leading the economy. U.S. economic performance also affects the electoral success of the president and the president's party. There are numerous studies showing that the electoral success of the president and president's party depends on U.S. economic performance through time (e.g., see Fair 1978; Fiorina 1981; Rosenstone 1983; Kiewiet and Rivers 1985; Markus 1988; Erikson 1989; Erikson, Bafumi, and Wilson 2001). …

Purpose: We assess the medium and long-term morbidity of buccal mucosal graft (BMG) harvest for urethroplasty, and evaluate the effect of nonclosure of the graft harvest site on postoperative pain. Materials and Methods: A questionnaire was mailed to 110 men who underwent BMG urethroplasty between January 1, 1997 and August 31, 2002. Demographic data and side effects of BMG harvest, including oral pain, sensation and intake, were assessed postoperatively. A prospective study was then performed to compare 20 unselected men whose BMG donor site was closed with a group of 20 men in whom it was left open using a 5-point analog pain score that was completed twice daily for the first 5 postoperative days. Results: A total of 49 men with a median age of 49 years (range 23 to 73) returned questionnaires relating to 57 BMG harvests. Of the graft harvests 47 (83%) were associated with postoperative pain, which was worse than expected in 24 (51%). Of the 57 patients 51 (90%) resumed oral liquid intake within 24 hours and 44 (77%) resumed normal diet within 1 week. Postoperative side effects included perioral numbness in 39 (68%) patients with 15 (26%) having residual numbness after 6 months, initial difficulty with mouth opening in 38 (67%) with 5 (9%) having persistent problems, changes in salivation in 6 (11%) and mucous retention cyst that required excision in 1 (2%). The men in the prospective donor site study had a median age of 51 years (range 24 to 70). Mean pain score for patients with donor site closure was 3.68 and was significantly higher than that for patients without donor site closure (2.26, p Conclusions: Buccal mucosal graft harvest is not a pain-free procedure. Closure of the harvest donor site appears to worsen this pain and it may be best to leave harvest sites open. The main long-term complications are perioral numbness, persistent difficulty with mouth opening and change in salivary function.

We propose a political transaction cost theory of the politics of administrative design and then evaluate the theory using data on the initial design attributes of 141 federal administrative agencies created legislatively between 1879 and 1988. The theory posits that the enacting coalition attempts to strategically manipulate administrative design attributes and therefore political transaction costs for future coalitions seeking to affect agency policy. Based on perceptions of the probability of political holdup and resulting losses, the enacting coalition alters political transaction costs to optimize expected benefits. We gauge the perceived probability of political holdup using measures of executive-legislative conflict, coalitional conflict, electoral turnover, and party hegemony. Using structural probit analysis, the results show that these factors significantly affect agency design attributes involving structure, process, and monitoring. Thus, the statistical analysis is consistent with the theory t...