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The key to understanding agenda setting is how and why conditions become defined as public problems. This process has been dubbed problem definition by past literature, yet past work offers little more than descriptive accounts of the process. We apply a threshold model to explain how problem definition can exhibit both incremental and punctuated change. We then demonstrate the model by explaining redefinition of the sexual harassment issue following the Clarence Thomas Supreme Court nomination hearings. Using Box-Tiao (1975) and nonlinear time varying parameter regression methods, we show that the hearings permanently altered individual and social nonacceptance of sexual harassment, as well as initiated a process of positive feedback. Given that there are many conditions similar to sexual harassment, and given that disturbances are quite frequent, sudden change should be a common feature of the American system.

This study explores how politics affects the propensity of the American states to pursue equity in local outcomes. Using state education finance as an object of analysis, we develop a theoretical model that emphasizes the social welfare implications of equity versus allocative efficiency and distributive politics. We then hypothesize that the relative liberalism of a state's citizens and institutions should affect both the weight attached to equity in the social welfare function and the ability of the courts to alter those weights. Using a panel design, we explain state funding allocations to 8,048 local school districts from 1992 through 1996. The statistical results show that the relative emphasis on equity differs substantially across states based on political values. States with conservative citizens and institutions place less emphasis on revenue equity than states with liberal citizens and institutions. Judicial mandates are generally unsuccessful in producing more equal allocations but are more suc...

We analyze the relationship between public approval and presidential success in Congress using time-varying parameter regression methods. Cues from constituency, ideology, and party dominate congressional vote choice, so the effect of public approval of the president is typically marginal. Because the strength of these primary cues varies through time, the effect of public approval on presidential success should also be time varying. Analysis of conflictual roll-call votes from 1953 through 2000 using the time-varying Kalman filter reveals that the effect of public approval on presidential success is marginal and changing through time. These models assume that the time variation is a stochastic process, and finding time-varying relationships may indicate model misspecification. Our theory, however, suggests that this time variation depends on a systematic factor—partisanship. A better specified model that allows systematic parameter variation confirms that the level of partisanship conditions the relation...

Background Examination under anesthesia (EUA) with diagnostic vaginoscopy is an invaluable method in the lower genital tract assessment of pediatric and adolescent females. The literature on this topic remains scarce. Methods This is a retrospective medical notes review of all patients who underwent EUA with or without vaginoscopy over the past 5 years at a pediatric and adolescent gynecology unit specializing in disorders of sex development (DSD). Results From 2005 to 2010, 83 patients underwent 92 procedures. All procedures were performed under general anesthesia, and a 3-mm pediatric cystoscope was used for vaginoscopy. Of the 92 cases, 33 (36%) were EUA alone and 59 (64%) consisted of a combined EUA and vaginoscopy. The mean age was 13.3 ± 3.7 years. The most common indications included assessment for reconstructive surgery (33.7%), vaginal stenosis (21.7%), vaginal discharge (19.6%), vaginal bleeding (16.3%), and pelvic pain (8.7%). Most (61%) of those presenting for assessment for reconstructive surgery had a DSD and history of surgical correction in early childhood. In 88 cases (96%), the evaluation was satisfactory and a diagnosis was reached or normality confirmed. Four cases (4%) required further investigation. No significant intraoperative or postoperative complications were encountered. Of the 92 cases, 15 (16%) required a further minor procedure, which was performed at the time of the EUA/vaginoscopy. Another 33 (36%) required further major surgery, which was performed at a later date. Conclusion EUA/vaginoscopy is a safe and highly useful method in the assessment of the lower genital tract in pediatric and adolescent patients.

Introduction Isolated bilateral simplex ectopic ureters (BSEUs) are rare but pose a therapeutic challenge: ureteric reimplantation alone does not accomplish continence in all. Identifying the patients needing additional procedures for continence early could prevent multiple operations. Objective Potential preoperative indicators for postoperative continence are explored in eight BSEU girls without cloacal, anorectal, or spinal anomalies. Study design With institutional approval, all patients with BSEU between 1985 and 2012 were retrospectively reviewed. Cystoscopy determined the site of ureteric ectopia (6 of 16 at the bladder neck [BN], 5 of 16 below the BN, and 5 of 16 in the distal urethra). Bladders were assessed by a combination of ultrasound, urodynamics, micturating cystourethrogram, cystoscopic, and intraoperative observations. Expected bladder capacity for age (EBCA) was calculated by 30 ml + (30 ml × age in years) or 38 ml + (2.5 ml × age in months) for children greater or less than 2 years, respectively. Continence outcomes were appraised at a minimum of 4 years. The small number of patients precludes credible statistical analysis and therefore raw data are presented. Results Patients underwent cross-trigonal ureteric reimplantation at 1–5.5 years, in five without BN surgery and in three with a Young–Dees–Leadbetter BN tightening. Of those without BN surgery at reimplantation, four achieved satisfactory continence for their age, but one has had multiple procedures culminating in BN closure, ileocystoplasty, and Mitrofanoff. Among the BN-tightening group, one was in nappies at 4 years, one had residual stress incontinence after two further BN injections, and one proceeded to artificial urinary sphincter after two BN injections. Five patients had significant renal impairment. Discussion Patients with satisfactory continence after reimplantation alone and those needing further procedures tended to differ in their preoperative observations of bladder capacity and apparent BN competence. This study suggests preoperative observations of an empty bladder on serial ultrasound and/or a wide-open BN with small or even moderate bladder capacity at cystoscopy to indicate the need for BN surgery. In contrast, children with bladder filling to at least 30% of expected bladder capacity for age on preoperative ultrasound or apposition of the BN at cystoscopy may achieve satisfactory continence after ureteric reimplantation alone. Bladder capacity as an indicator of BN competence can also be correlated to continence outcomes in previously published series. Polyuria associated with renal impairment can exacerbate the challenge for continence. Conclusion Preoperative bladder capacity appears to be an indicator of inherent BN function and a thorough assessment of the urinary tract by cystoscopy, ultrasound, micturating cystourethrogram, and functional imaging may guide the surgeon on the need for BN surgery at the time of ureteric reimplantation. Where continence remains elusive, patients should be counselled that a further BN injection is occasionally of value although more significant BN procedures are required for most. Table. Continence outcomes for individual patients at their last FU. Cystoscopic observations regarding bladder size/BN competence and observed bladder volumes prior to cross-trigonal ureteric reimplantation with or without BN tightening. Continence outcome Patient Age at FU Pre-ureteric reimplantation cystoscopic finding bladder filling on US Postoperative bladder function assessment After ureteric reimplantation alone Continent 1 4 y Not recorded 21 ml at 7 mo (36% EBCA) 100 ml at 4 y (67% EBCA) 2 6 y Good capacity 14 ml at 3 mo (30% EBCA) 281 ml at 6 y (130% EBCA) 4 11 y Not recorded 71 ml at 2.5 y (68% EBCA) 450 ml at 11 y (125% EBCA) Enuretic 5 8 y BN apposition 230 ml at 5 y (125% EBCA) Capacity maintained Proceeding to BNC cystoplasty 8 20 y Small capacity BN wide open Not recorded 220 ml at 14 y (50% EBCA) after colposuspension Reimplantation with BN tightening In nappies 3 4 y Moderate size BN wide open 14 ml at 12 mo (20% EBCA) 47 ml at 2.5 y (50% EBCA) Proceeding to BNI 6 20 y Moderate size BN wide open Not recorded Urodynamics: at 8 y 100% EBCA and at 20 y stress leak Proceeding to AUS 7 16 y Small capacity Empty on serial US at 5 y 188 ml at 12 y (50% EBCA) after BNI The EBCA is calculated for children aged below 2 years (38 ml + 2.5 ml × age in months) and those above 2 years (30 ml + 30 ml × age in years). Bladder filling is expressed as a percentage of EBCA (measured volume/EBCA × 100). AUS = artificial urinary sphincter; BN = bladder neck; BNC = bladder neck closure; BNI = bladder neck injection; EBCA = expected bladder capacity for age; FU = follow-up; mo = months; US = ultrasound; y = years. Full-size table Table options View in workspace Download as CSV

Please cite this paper as: Nakhal R, Wood D, Woodhouse C, Creighton S. False-positive pregnancy tests following enterocystoplasty. BJOG 2011; DOI: 10.1111/j.1471-0528.2011.03031.x. People with major congenital urological or neurological malformations invariably require bladder reconstruction with enterocystoplasty in early childhood. The improvement of the surgical management of these children has reflected significantly on their life expectancy. As a result, more young people with enterocystoplasty are being transitioned to adolescent clinics where they receive the usual counselling about sexual health and pregnancy risks. However, the possibility of false-positive urinary pregnancy tests in these young women remains an overlooked but essential message. The lack of awareness about this fact can result in significant patient anxiety and the potential for unnecessary interventions as exemplified by the three cases we have encountered.

To investigate sexual function and quality of life in adolescent and adult women with classic bladder exstrophy (BE).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.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.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.

Scholars generally agree that political elites in the US are polarized. Yet most of our evidence, especially longitudinal evidence, is built on proxy measures of elite ideology that fail to identify the unique dimensions that drive the cleavages between the parties. And our understanding of when elite polarization reemerged is also unclear. This study leverages the party platforms, along with the tools of content analysis, to shed new light on elite polarization. We find that, consistent with the literature, elite polarization is an asymmetric phenomenon driven by Republicans primarily motivated by economic issues. Further, we show that modern elite polarization emerged starting with the 1980 election.

Objective To examine the management and long-term outcomes of transverse vaginal septae. Design Observational study with cross-sectional and retrospective arms. Setting Tertiary referral centre specialising in Mullerian anomalies. Population Forty-six girls and women with a transverse vaginal septum. Methods Data from medical records of all cases (1998–2013) of transverse vaginal septae were collected and reviewed. Patients over 16 years of age also completed a questionnaire. Main outcome measures Presentation, examination findings, investigations, surgery, and long-term reproductive outcomes. Results The septae in the study were described as follows: 61% (95% CI 0.46–0.74) were imperforate, and presented with obstructed menstruation; 39% (95% CI 0.26–0.54) were perforate, and presented with a variety of concerns; 72% (95% CI 0.57–0.83) were low, 22% (95% CI 0.12–0.36) were mid-vaginal, and 6% (95% CI 0.02–0.18) were high; 33% were managed via an abdominoperineal approach, 59% were managed via a vaginal approach, and 6% had laparoscopic resection (one patient did not have surgery); 11% (95% CI 0.05–0.23) of patients presented with reobstruction, all following abdominoperineal vaginoplasty; 7% presented with vaginal stenosis, two following vaginal resection and one following the abdominoperineal approach; 61% of questionnaires were returned. These results showed that 22/23 patients were menstruating and one had a hysterectomy, 74% had been sexually active, 35% had dyspareunia, and 36% complained of dysmenorrhoea. There were seven pregnancies, with one termination and six live births, all following the vaginal excision of a transverse vaginal septum. Conclusions Transverse vaginal septae resected vaginally or laparoscopically have low complication rates and good long-term outcomes. Complex septae require more extensive surgery, with an increased risk of complications.

Cloacal anomalies occur when failure of the urogenital septum to separate the cloacal membrane results in the urethra, vagina, rectum and anus opening into a single common channel. The reported incidence is 1:50,000 live births. Short-term paediatric outcomes of surgery are well reported and survival into adulthood is now usual, but long-term outcome data are less comprehensive. Chronic renal failure is reported to occur in 50 % of patients with cloacal anomalies, and 26–72 % (dependant on the length of the common channel) of patients experience urinary incontinence in adult life. Defaecation is normal in 53 % of patients, with some managed by methods other than surgery, including medication, washouts, stoma and antegrade continent enema. Gynaecological anomalies are common and can necessitate reconstructive surgery at adolescence for menstrual obstruction. No data are currently available on sexual function and little on the quality of life. Pregnancy is extremely rare and highly risky. Patient care should be provided by a multidisciplinary team with experience in managing these and other related complex congenital malformations. However, there is an urgent need for a well-planned, collaborative multicentre prospective study on the urological, gastrointestinal and gynaecological aspects of this rare group of complex conditions.

Congenital anomalies of the kidneys and urinary tract (CAKUT) encompass a broad range of developmental malformations of the kidney and the lower urinary tract. The many malformations are now detected by fetal ultrasound screening, but cases may still present for the first time in childhood with symptoms of failure to thrive or during investigation of urinary tract infection. In adults developmental abnormalities may still present with abnormal urinalysis, renal stones, hypertension or chronic kidney disease or as an incidental finding.

In order to maintain or enhance deliverability of gas storage wells in the Clinton Sand in Northeast Ohio an annual restimulation program has been in place since the late sixties. The program calls for as many as twenty hydraulic fractures and refractures per year. Several wells have been refractured three to four times while there are still wells that have only been fractured once in the past thirty years. As the program continues many wells will be stimulated a second, third or fourth time. This paper summarizes an attempt to carefully study the response of the Clinton sand to hydraulic fractures and identify the performance drivers in each series of frac jobs. Do the performance drivers remain the same for the later fractures (second, third and fourth frac jobs) as they were in the first ones? Or do they change? This paper attempts to answer such questions. Identification of major performance drivers becomes important when new jobs are to be designed. They not only play an important role in enhancing the response of the wells to new stimulation jobs; but also may prove to be an important economic factor in the design of new stimulation procedures. If for instance it is concluded that an increase in proppant volume does not influence the stimulation outcome after the second refracture, then fewer resources can be used for proppant volume and be directed toward parameters that are more influential. This study employs a combined neural network and fuzzy logic tool to identify the performance drivers.

Past research on budgeting has ignored the existence of an equilibrating tendency in U.S. federal revenues and expenditures through time. Using time series error-correction models, show the existence of such an equilibrating tendency in federal budgets from 1904 to 1996, and theorize that it is due to the balanced-budget norm. Time-varying parameter estimation methods are then used to reveal substantial variations in the strength of the equilibrating tendency through time. Descriptive evidence from the time-varying coefficients shows that the equilibrating tendency in the federal budget was actually weaker prior to the Great Depression and the acceptance of Keynesian principles. There is little evidence of temporal change in the equilibrating tendency in the modern era due to partisanship or divided government. The results suggest that the balanced budget force is important in changing federal revenues and expenditures, but in a manner more complex than has been suggested by facile theories of the past.

Influencing the policy agenda has long been viewed as one of the most important sources of political power. For decades, scholars have maintained that the president has the most significant role in setting the policymaking agenda in Washington, but little systematic empirical work has been done to measure the president's influence. We explore the president's success in focusing the issue attention of Congress and the mass media by evaluating time-series measures of presidential, mass media, and congressional attention to five issues: crime, education, health care, U.S.–Soviet relations, and the Arab-Israeli conflict. We find that most of the time the president reacts, responding primarily to fluctuations in media attention and world events. In domestic policy, we find a more interactive relationship, one that appears to offer the president the opportunity to act in an entrepreneurial fashion to focus the attention of others in the system on major presidential initiatives.

Theories of agenda setting ignore the macrodynamics of shifts in attention to policy issues in the American system of separated powers. Changes in attention to issues emerge from interactions between the three branches of government, as well as interactions between the government and the public. To map these complexities, we use vector autoregression methods to sort out the causal sequences and macrodynamics of issue attention over time between systemic and institutional agendas for three broad issue areas. The analyses reveal significant interactions among the institutional agendas and between the systemic and institutional agendas, but provide more support for a top-down pattern of issue attention than for the bottom-up pattern suggested by most past literature. Reductionist theories positing either a linear, unidirectional sequence of issue movement or randomness should be viewed cautiously in light of these findings, which point to the need for more holistic views of agenda setting.

This paper 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 profile of diseases that specifically affect men has increased in recent years, and charities have had a major role in raising public awareness and funding for these conditions. Now that these charities have gained attention, their influence in the field of men's health should be assessed.

We propose a dynamic model of representation that posits that representatives adapt through time to minimize the distance between policy choices and constituent, global, and personal preferences. Several hypotheses flow from the dynamic model: (1) equilibria develop through time in senator policy choice; (2) representatives adapt through time to global, as well as constituent preferences; (3) the manner in which adaptation occurs depends on the strength of the representative's personal ideology; (4) the manner in which adaptation occurs depends on various measures of constituency efficiency. We use pooled time-series cross-section analysis of covariance techniques to evaluate the preceding hypotheses. The analysis shows that senators integrate constituent, global, and personal preferences. Equilibria exist through time in Senator Policy Liberalism Adaptation to and from the equilibria depends on global and constituent preferences and efficiency. The manner of adaptation also depends on the strength of the...

Theoretical and empirical work on public policy agenda setting has ignored foreign policy. We develop a theory of foreign policy agenda setting and test the implications using time-series vector autoregression and Box-Tiao (1975) impact assessment methods. We theorize an economy of attention to foreign policy issues driven by issue inertia, events external to U.S. domestic institutions, as well as systemic attention to particular issues. We also theorize that the economy of attention is affected by a law of scarcity and the rise and fall of events in competing issue areas. Using measures of presidential and media attention to the Soviet Union, Arab-Israeli conflict, and Bosnian conflict, we show that presidential and media attentions respond to issue inertia and exogenous events in both primary and competing issue areas. Media attention also affects presidential attention, but the president does not affect issue attention by the media.

Objective In 2001, this team published an observational study of the clinical outcomes of a cohort of adolescent girls born with ambiguous genitalia. The poor outcomes observed represented a major scientific challenge to the standard practice of childhood feminising genital surgery. That publication was one of several contributing to a call for change in surgical practice, which culminated in the publication of the Chicago Consensus Document in 2006. The aim of this current study was to repeat the same evaluation of clinical outcomes on a recent cohort of adolescent girls and compare the two cohorts to identify differences in adolescent outcomes which may indicate a change in paediatric surgical practice. Methods This was an observational study of a current cohort of adolescent girls treated in childhood for ambiguous genitalia and referred to a specialist adolescent disorders of sex development (DSD) service for assessment. Data were collected on surgical history, genital examination findings and treatment recommendations for 30 consecutive adolescents over a 5-year period. Findings were compared with those of a similar cohort of adolescent girls published over a decade previously. Results Clitoral surgery remained common (93% vs 100%, current cohort vs historical cohort). However, concomitant vaginoplasty was performed less frequently (80 vs 100% current vs historical). Vaginoplasty revision surgery was also less commonly required (65 vs 81%), although 24% of the recent cohort still required major revision surgery prior to intercourse. There was some improvement to the cosmetic outcomes as deemed by the surgical team using the same criteria as the previous report. Conclusions This study provides some slight evidence of recent practice change. There was a small reduction in the number of vaginoplasties performed in childhood and an improvement in vaginoplasty outcomes and cosmesis. However, there was no identifiable change in management of clitoromegaly and the numbers of clitoral reduction operations remained high. This is surprising given the clear evidence of a detrimental impact of surgery on clitoral sensation and sexual function.

A quantitative study of common forensic evidence collection devices for the recovery of low-explosive residues from non-porous glass and plastic is presented herein. Swabbing materials including cotton, rayon, Nomex(®) (poly(isophthaloylchloride/m-phenylenediamine)), Teflon/Teflon-coated fibreglass (polytetrafluoroethylene) and adhesive-coated tapes were used to collect known quantities of up to 14 forensically relevant inorganic and organic anion and cation species from both surfaces. Analysis was performed using two validated ion chromatography methods. This study revealed that all swabs and surfaces contributed highly variable levels of interfering ionic species and that swabbing materials showed variance in the quantities and total number of analytes recovered from both surfaces. Teflon and Nomex(®) materials demonstrated the most promise due to their ability to collect and release analytes into simple extraction solvents as well as displaying relatively low endogenous interference. In parallel, the ability to extract residue directly from both surfaces via the addition of a suitable extraction solvent was investigated instead of swabbing. This work highlights that direct solvent extraction from a surface should be considered as an alternative approach, especially for small areas or objects. To the best of our knowledge, this work represents the most comprehensive study of the efficiencies of sample collection technologies for low-explosive residues prior to analysis by ion chromatography.

To evaluate the magnetic resonance (MR) imaging appearance of the testes in women with complete androgen insensitivity syndrome (CAIS), including any benign or malignant changes.This was a retrospective review of the testicular MR images and histologic reports from 25 patients with CAIS who chose to retain their testes beyond age 16 years and who were imaged between January 2004 and December 2010. Ethical approval was obtained, and informed consent was obtained from each subject to review the medical records, images, and histologic slides and reports. Imaging and histologic findings were compared.Twelve patients (mean age, 24 years; age range, 18-39 years) retained their testes and 13 (mean age, 22 years; age range, 17-37 years) eventually underwent gonadectomy. Review of the MR images showed that testicular parenchyma was heterogeneous in 30 of 46 testes (65%). The most common changes on MR images included simple-looking paratesticular cysts (34 of 46 testes, 74%) and low-signal-intensity, well-defined Sertoli cell adenomas (26 of 46 testes, 56%). Correlation of the histologic and MR imaging findings showed that MR imaging could correctly depict the presence or absence of Sertoli cell adenomas in 19 of 23 testes (83%). Paratesticular cysts were correctly detected in 22 of 23 testes (96%). Microscopic examination showed that the testes were composed of atrophic seminiferous tubules, whereas germ cells were found in 13 of 26 testes (50%). All paratesticular cysts were confirmed to be benign; however, a focus of intratubular germ cell neoplasia was found in a Sertoli cell adenoma. Premalignant foci were detected in three patients, two with intratubular germ cell neoplasia and one with sex cord tumor with annular tubules. No invasive cancers were found.MR imaging is accurate in the detection of testicular changes, including paratesticular cysts and Sertoli cell adenomas. Although these changes are usually benign, Sertoli adenomas can sometimes harbor premalignant lesions. MR imaging cannot depict premalignant changes; therefore, the standard of care for patients with CAIS should remain gonadectomy after puberty.

This chapter aims to examine the emergency presentation of urological malignancies. Breathlessness or other respiratory symptoms and acute renal failure are both scenarios which prompt urgent diagnosis and management. Up to 10 % of testicular cancers present with metastases. Spinal cord compression can be devastating but if recognized and treated early its impact can be dramtically reduced.

The incidence of ureteric colic is probably unchanged by pregnancy, ranging from 1 in 1,500 to 1 in 2,500 – the same as in nonpregnant women (Coe et al. 1978). Some authors have suggested the incidence increases significantly up to 1 in 200 (Cormier et al. 2006), although evidence to support this is limited. Ureteric colic in pregnant women tends to occur during the second or third trimester (Stothers and Lee 1992). Both urinary calcium and uric acid excretion increase in pregnancy (predisposing to stone formation), so too do urinary citrate and magnesium levels (protecting against stone formation). The development of a ureteric stone during pregnancy is a significant event for four important reasons

We examine the determinants of change in state government indebtedness from 1961 through 1989 using a pooled time series cross-sectional analysis. The analysis reveals that debt is primarily a function of economic conditions reflecting both the need to borrow and the capacity of states to repay debt. However, political factors such as culture, partisan competition, and electoral cycles also affect state debt. We also find very weak evidence that tax and expenditure limitations, ironically, may increase state indebtedness, while constitutional debt limitations have no effect upon slowing the growth of state debt.

The founders of the American republic believed presidents should be wise and virtuous statesmen consistently advocating community interests when conducting American foreign policy. Yet the most common theoretical model used today for explaining the behavior of politicians is grounded in self-interest, rather than community interest. This book investigates whether past presidents acted as noble statesmen or were driven by such self-interested motivations as re-election, passion, partisanship, media frenzy and increasing domestic support. The book also examines the consequences for the nation of presidential behavior driven by self-interest. Between 1945 and 2008, presidents issued 4,269 threats to nineteen different countries. Professor B. Dan Wood evaluates the causes and consequences of these threats, revealing the nature of presidential foreign policy representation and its consistency with the founding fathers' intentions.