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Objectives: While efforts have been made to study erectile function in patients with urethral stricture, very few prior investigations have specifically assessed erectile function in men with failed hypospadias surgery. We set forth to assess the baseline erectile function of men with hypospadias failure presenting for urethroplasty as adults., Methods: Retrospective data was analyzed on 163 adult patients with prior failed hypospadias repair who presented for urethroplasty from 2002-2007 at two sites in the United States and Italy. All patients had completed the International Index of Erectile Function (IIEF) pre-operatively. Standard IIEF-6 categories were used to assess baseline level of erectile dysfunction (ED) defined as none (≥ 26), minimal (18-25) ,moderate (11-17), and severe (≤ 10). A subset of 13 hypospadias patients prospectively completed the IIEF questionnaire pre and post- operatively., Results: The mean age at presentation for urethroplasty was 39.7 years. Based on IIEF-6 scores, 54% of patients presented with some degree of ED with 22.1%, 3.7%, and 28.2% reporting severe, moderate and mild ED respectively. While the oldest patient population (>50) had the highest incidence of severe ED (38.9%), the youngest age group (=30) had a 60% rate of ED with 18% classified as severe (Table I). Subset analysis of 13 failed hypospadias patients following urethroplasty revealed that 11 (85%) patients had the same or improved erectile function following surgery., Conclusions: Patients presenting for repair after hypospadias failure often require complex penile reconstruction impacting both urinary as well as sexual quality of life. Among these patients there appears to be a high baseline prevalence of ED. Older patients had a higher incidence of more severe ED; however, the majority of younger patients still presented with some form of ED and a significant number with severe ED. Urethroplasty does not appear to negatively impact erectile function in men with previous hypospadias failure; however a disease specific questionnaire is needed to fully address this issue.

Background: The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions., Purposes: The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities., Methods: A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective., Results: The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care., Conclusions: The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.

The Assessing Levels of Physical Activity (ALPHA) health-related fitness test battery is a set of reliable, valid, and feasible tests to assess health-related physical fitness in children and in adolescents. The aim of this study was to examine the reliability of this battery in adolescents with Down syndrome (DS). The extended ALPHA health-related fitness test battery was performed twice within 1 month in 17 apparently healthy adolescents, aged 12-18 years, with DS who had an intelligence quotient ≥ 35. Intraclass correlation coefficient (ICC) was used to determinate test-retest reliability, and nonparametric Wilcoxon signed rank test was used to compare mean differences between measurements. With the exception of subscapular skinfold test, which obtained a moderate agreement (ICC = 0.64), all tests had a very high reliability: the 20-m shuttle-run test (ICC = 0.86), the right handgrip strength test (ICC = 0.86), the left handgrip strength test (ICC = 0.86), the standing broad jump test (ICC = 0.85), body mass index (ICC = 0.95), waist circumference (ICC = 0.98), triceps skinfold (ICC = 0.85), and the 4 × 10-m shuttle-run test (ICC = 0.92). There were no significant differences (all p > 0.05) in any of the tests. The ALPHA health-related fitness battery is reliable for measuring health-related components of fitness in adolescents with DS.

Nanowires with higher tungsten (W) concentration and enhanced conductivity were grown via the laser assisted electron beam induced deposition (LAEBID) technique using tungsten hexacarbonyl W(CO)6 as the gas precursor. Periodic, pulsed laser irradiation facilitated CO desorption during growth by heating the deposit. Deposit purity improved with laser pulse width up to the threshold for pyrolytic laser chemical vapor deposition (LCVD). Higher resolution was also observed and was attributed to reduced CO incorporation and higher deposit density. The optimal composition and lowest resistivity was achieved by synchronizing the electron beam induced deposition and laser assist such that (1) the electron beam induced deposit is less than a monolayer per cycle and (2) the laser induced heating is just below the LCVD threshold.

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The incidence of specific aetiologies of urethral stricture disease has been reported from a variety of series throughout the world. Most reported urethral stricture series are from single institutions or from a specific region of the world. We provide a multi-centred series to compare aetiologic incidence between differing regional populations., Objective: To better understand distinct regional patterns in urethral stricture aetiology and location among distinct regional populations., Patients and Methods: Data on 2589 patients who underwent urethroplasty from 2000 to 2011 were collected retrospectively from three clinical sites, including 1646 patients from Italy, 715 from India and 228 from the USA. Data from all sites were single-surgeon series. As the data from the Italian and US cohorts were similar in aetiology, location and demographics, we combined these data to form group 1, and compared this group with men in the Indian cohort, group 2. Age, stricture site and primary stricture aetiology were identified for each patient. Stricture site and primary aetiology were determined by the treating surgeon. Primary aetiology was defined as iatrogenic, trauma including pelvic-fracture-related urethral injury (PFUI), lichen sclerosus (LS), infectious, congenital, or unknown., Results: There were more penile strictures (27 vs 5%) and fewer posterior urethral stenoses (9 vs 34%) in group 1. There were more iatrogenic strictures identified in group 1 (35 vs 16%). When comparing the aetiology of iatrogenic strictures alone, more strictures in group 1 were attributable to failed hypospadias repair (49 vs 16%). More patients presented with LS (22 vs 7%) and external trauma (36 vs 16%) in group 2. Prevalence of strictures of infectious aetiology was low (1%) with similar proportions between the two groups., Conclusions: We have shown that significant regional differences in stricture aetiology exist in a large multicentre cohort study. Group 1 had a higher proportion of penile strictures, largely owing to more iatrogenic strictures and, in particular, failed hypospadias repair. Group 2 had a higher proportion of PFUI and LS-associated urethal stricture. Identified infection-related urethral stricture was rare in all cohorts. Significant regional differences in stricture aetiology exist and should be considered when analysing international outcomes after urethroplasty. These data may also help the development of international disease prevention and treatment strategies., (© 2012 BJU International.)

This article presents an overview of reconstruction of lower urinary tract injury caused by radiation therapy for prostate cancer. Discussions include cause, patient evaluation, reconstructive techniques, and outcomes following repair., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: Lichen sclerosus is an inflammatory skin disorder affecting anogenital areas in males and females that is associated with squamous cell carcinoma. However, there is a lack of data on the role of biomarkers for predicting lichen sclerosus progression to squamous cell carcinoma. We focused on early protein markers of squamous cell carcinoma and their expression in lichen sclerosus to improve the mechanistic and diagnostic understanding of lichen sclerosus., Material and Methods: We performed an extensive PubMed® and MEDLINE® search for protein markers found in early stages of vulvar and penile squamous cell carcinoma, and their prevalence in associated lichen sclerosus lesions., Results: In recent years several markers have been implicated as precursor markers for malignant transformation of lichen sclerosus into squamous cell carcinoma, including p53, Ki-67, γ-H2AX, MCM3 and cyclin D1. These proteins are up-regulated in lichen sclerosus of the vulva/penis and squamous cell carcinoma. Various levels of evidence show an association between lichen sclerosus and squamous cell carcinoma. p16 is over expressed in penile and vulvar squamous cell carcinoma associated with human papillomavirus infection but conflicting reports exist about its expression in lichen sclerosus. The angiogenesis markers vascular endothelial growth factor and cyclooxygenase-2 are expressed at higher levels, and microvessel density is increased in vulvar lichen sclerosus and squamous cell carcinoma, indicating a possible similar association in penile lichen sclerosus., Conclusions: Only a minority of lichen sclerosus cases are associated with squamous cell carcinoma. However, the therapeutic implications of a squamous cell carcinoma diagnosis are severe. Clinically, we lack an understanding of how to separate indolent lichen sclerosus cases from those in danger of progression to squamous cell carcinoma. Several protein markers show promise for further delineating the pathobiology of lichen sclerosus and the potential malignant transformation into squamous cell carcinoma., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We determined whether including a care coordination system to manage the referral process for hematuria would lead to improved quality of care., Materials and Methods: Inflection Navigator, a protocol based, electronic medical record enabled care coordination system, was developed to support primary care physicians evaluating newly discovered hematuria. We studied the system for patients referred for microscopic and gross hematuria from May 2009 to May 2010. We compared outcomes in these 106 patients and in 105 referred to our urology department for hematuria during the same period who did not use the system., Results: Patients in the care coordination group completed the evaluation in a significantly shorter time with more than a 1-month difference in time between referral and the completion of the imaging and cystoscopy components of the assessment (mean 40.9 vs 74.1 days, p <0.05). This system potentially lowered health care costs by decreasing the mean ± SD number of urology visits needed to complete an evaluation from 2.1 ± 1.5 in the standard referral group to 1.6 ± 1.4 in the care coordination group (p <0.05)., Conclusions: A protocol based care coordination system for hematuria decreased the time needed to complete an evaluation and decreased the number of overall visits required to make a final diagnosis. Thus, the Inflection Navigator system is an example of an electronic medical record enabled process innovation that can improve the efficiency of care while potentially lowering health care costs., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction: "Obesity" is considered a feature of youth with DS but whether "low physical fitness" is also a feature is unknown., Objective: The aim of this case-control study was to compare the levels of fatness and fitness in adolescents with and without DS., Methods: Participants included 17 (5 girls) adolescents with DS aged 12-18 years and a control group of 94 (45 girls) adolescents without DS aged 12-16 years. The ALPHA health-related fitness test battery for children and adolescents was selected to assess fatness and fitness in both groups., Results: There were no differences in levels of fatness between groups (all P > 0.27). Adolescents with DS had lower levels of fitness in all the tests than adolescents without DS (all P < 0.001)., Conclusion: Adolescents with DS have similar levels of fatness and lower levels of fitness than their peers without DS., (Copyright © AULA MEDICA EDICIONES 2013. Published by AULA MEDICA. All rights reserved.)

Rheumatoid arthritis (RA) is a chronic systemic disease that leads to increases in health system economic burden through direct and indirect costs, including chronic treatment, reduced productivity and premature mortality. Anti-TNF agents have represented a major advance in the treatment of RA. The most commonly used (adalimumab, etanercept and infliximab) have demonstrated their cost-effectiveness at label doses. However, physicians may need to adapt the treatment by increasing the dose when a drug is not effective enough or by reducing it when there is a sustained effectiveness. In a cross-sectional study conducted in our hospital in which information from RA patients treated with anti-TNF drugs under conventional and modified doses were collected, the authors analyzed the costs of the medication in order to estimate the mean patient-year cost, the annual costs related to clinical efficacy and the cost per responder patient to anti-TNF treatment when dosage modification is undertaken in daily clinical practice.

The ion beam induced nanoscale synthesis of platinum nanowires using the trimethyl (methylcyclopentadienyl)platinum(IV) (MeCpPt(IV)Me3) precursor is investigated using helium and neon ion beams in the gas field ion microscope. The He(+) beam induced deposition resembles material deposited by electron beam induced deposition with very small platinum nanocrystallites suspended in a carbonaceous matrix. The He(+) deposited material composition was estimated to be 16% Pt in a matrix of amorphous carbon with a large room-temperature resistivity (∼3.5 × 10(4)-2.2 × 10(5) μΩ cm) and temperature-dependent transport behavior consistent with a granular material in the weak intergrain tunnel coupling regime. The Ne(+) deposited material has comparable composition (17%), however a much lower room-temperature resistivity (∼600-3.0 × 10(3) μΩ cm) and temperature-dependent electrical behavior representative of strong intergrain coupling. The Ne(+) deposited nanostructure has larger platinum nanoparticles and is rationalized via Monte Carlo ion-solid simulations which show that the neon energy density deposited during growth is much larger due to the smaller ion range and is dominated by nuclear stopping relative to helium which has a larger range and is dominated by electronic stopping.

Objective: To ascertain cystoscope durability in relation to usage and cost in the outpatient setting., Methods: Six flexible cystoscopes were provided to our outpatient clinic by 2 vendors. Five Wolf 7305.006S02 cystoscopes (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL) and 1 Olympus CYF-5 (Olympus America, Center Valley, PA) were used 2477 times over a 14-month study period. Prospective data were accumulated on each cystoscope including type of procedure, number of uses until mechanical failure, physician usage, and maintenance costs. All staff was trained in proper handling and maintenance of cystoscopes utilizing an Occupational Safety and Health Administration (OSHA) approved protocol. Retrospective comparison was performed of 1346 cystoscopic procedures during the previous 8 months before implementation of the processing protocol, with data including type and quantity of mechanical failures along with maintenance costs., Results: Five total study period failures occurred in 4 cystoscopes, with a mean of 495.4 procedures/failure. In 3 separate cystoscopes, failure occurred after 70 (perforation of working channel), 194 (leak in bending rubber), and 236 uses (hole in bending rubber). One cystoscope had 2 failures after 168 (cut in bending rubber) and 255 uses (failed leak test). During the retrospective period, there were 10 failures, with a mean of 134.6 procedures/failure. Four failures were secondary to crushed insertion tubes. Comparison of retrospective and study period costs revealed a 43.9% decrease from $9.64 per procedure to $5.41 per procedure., Conclusion: Outpatient flexible cystoscope durability seems directly related to optimization of handling and storage of cystoscopes. Costs related to mechanical failure were reduced with a rigorous reprocessing protocol., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine the most pressing issues facing academic urology training centers. The supply of urologists per capita in the United States continues to decrease. Stricter resident requirements, restriction of resident duty hours, and a Graduate Medical Education (GME) funding cap on resident education has led to significant challenges for academic centers., Methods: A 32-question survey was sent to Society of University Urologists members. Respondents defined themselves as academic faculty tenure track, program director, academic chair, program director and academic chair, clinical faculty nontenure track, and community faculty member., Results: A total of 143 of 446 members(32%) responded. A lack of funding was indicated as an obstacle to adding new residency positions (65% respondents) and recruiting new faculty (60% respondents). Residency positions not funded by GME (40% respondents) required either clinical or hospital dollars to support these slots. Most respondents (51%) indicated resident research rotations are funded with clinical dollars. Surgical skills laboratories are commonly used (85% respondents) and are supported mostly with hospital or clinical dollars. The majority of respondents (84%) indicated they would expand simulation laboratories if they had better funding. Other than urodynamics and ultrasound, urology residency training programs reported little income from ancillary dollars., Conclusion: There is a significant workforce shortage within urology training programs. Clinical revenue and hospital funding seem to be the main financial support engines to supplement the GME funding shortage, proficiency training, and faculty salary support for teaching. The current system of GME funding for urology residency programs is not sustainable., (Published by Elsevier Inc.)

The sorption of selenite (SeO(3)(2-)) and selenate (SeO(4)(2-)) onto Fe(3)O(4) nanomaterials produced by non microwave-assisted or microwave-assisted synthetic techniques was investigated through use of the batch technique. The phase of both synthetic nanomaterials was determined to be magnetite by X-ray diffraction. The average grain sizes of non microwave-assisted and microwave-assisted synthetic Fe(3)O(4) were determined to be 27 and 25 nm, respectively through use of the Scherrer's equation. Sorption of selenite was pH independent in the pH range of 2-6, while sorption of selenate decreased at pH 5 and 6. The addition of Cl(-) had no significant effect on selenite or selenate binding, while the addition of NO(3)(-) only affected selenate binding to the microwave assisted Fe(3)O(4). A decrease of selenate binding to both synthetic particles was observed after the addition of SO(4)(2-) while selenite binding was not affected. The addition of PO(4)(3-) beginning at concentrations of 0.1 ppm had the most prominent effect on the binding of both selenite and selenate. The capacities of binding, determined through the use of Langmuir isotherm, were found to be 1923 and 1428 mg Se/kg of non microwave-assisted Fe(3)O(4) and 2380 and 2369 mg Se/kg of microwave-assisted Fe(3)O(4) for selenite and selenate, respectively., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Objective: • Urethral strictures located in the fossa navicularis are common and are often managed with meatotomy or meatoplasty. • Few data have described the outcomes for men after urethroplasty or patient satisfaction following these procedures., Methods: • In all, 93 men at two different institutions underwent surgical repair of distal urethral stricture disease using meatotomy (73) or meatoplasty (20), with 13/20 (65%) of the latter group undergoing substitution urethroplasty. • In patients with lichen sclerosus (LS), all involved tissue was excised prior to reconstruction. • In a subset of men undergoing meatotomy, patient satisfaction was evaluated by questionnaire., Results: • Average clinical follow-up for men undergoing distal urethroplasty was 61 months. • Successful reconstruction requiring no further intervention occurred in 84% of men overall. Subgroup analysis revealed success in 87% of men with meatotomy, 75% with meatoplasty and 66% with substitution urethroplasty. • Men with LS had a significantly greater rate of stricture recurrence (20.5% vs 7.5%, P= 0.04). • Of the subset of men who completed a patient-based questionnaire 84% reported they were either satisfied or very satisfied with the results of their meatotomy., Conclusions: • We report the success of distal urethral stricture management. • Meatal strictures may be approached successfully in a stepwise manner progressing from meatotomy to meatoplasty for longer recurrent strictures, with a high overall success rate for meatotomy. • Although substitution grafts may be useful for men with longer distal strictures and those with LS, the risk of recurrence was significantly higher in this cohort., (© 2011 BJU INTERNATIONAL. NO CLAIM TO ORIGINAL US GOVERNMENT WORKS.)

Purpose: We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty., Materials and Methods: We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded., Results: The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05)., Conclusions: While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Particle-bound polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans (PCDD/Fs) in ambient air were monitored together with particulate matter less than 10 μm (PM(10)) at three sampling sites of the Andean city of Manizales, Colombia; during September 2009 and July 2010. PCDD/Fs ambient air emissions ranged from 1 fg WHO-TEQ m(-3) to 52 fg WHO-TEQ m(-3) in particulate fraction. The PM(10) concentrations ranged from 23 μg m(-3) to 54 μg m(-3). Concentrations of PM(10) and PCDD/Fs in ambient air observed for Manizales - a medium sized city with a population of 380,000 - were comparable to concentrations in larger cities. The highest concentrations of PCDD/Fs and PM(10) found in this study were determined at the central zone of the city, characterized by public transportation density, where diesel as principal fuel is used. In addition, hypothetical gas fractions of PCDD/Fs were calculated from theoretical K(p) data. Congener profiles of PCDD/Fs exhibited ratios associated with different combustion sources at the different sampling locations, ranging from steel recycling to gasoline and diesel engines. Taking into account particle and gas hypothetical fraction of PCDD/Fs, Manizales exhibited values of PCDD/Fs equivalent to rural and urban-industrial sites in the southeast and center of the city respectively. Poor correlation of PCDDs with PM(10) (r=-0.55 and r=0.52) suggests ambient air PCDDs were derived from various combustion sources. Stronger correlation was observed of PCDFs with PM(10). Poor correlation between precipitation and reduced PM(10) concentration in ambient air (r=-0.45) suggested low PM(10) removal by rainfall., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Event-related potentials (ERPs) may be used as a highly sensitive way of detecting subtle degrees of cognitive dysfunction. On the other hand, impairment of cognitive skills is increasingly recognised as a hallmark of patients suffering from multiple sclerosis (MS). We sought to determine the psychophysiological pattern of information processing among MS patients with the relapsing-remitting form of the disease and low physical disability considered as two subtypes: 'typical relapsing-remitting' (RRMS) and 'benign MS' (BMS). Furthermore, we subjected our data to a cluster analysis to determine whether MS patients and healthy controls could be differentiated in terms of their psychophysiological profile., Methods: We investigated MS patients with RRMS and BMS subtypes using event-related potentials (ERPs) acquired in the context of a Posner visual-spatial cueing paradigm. Specifically, our study aimed to assess ERP brain activity in response preparation (contingent negative variation -CNV) and stimuli processing in MS patients. Latency and amplitude of different ERP components (P1, eN1, N1, P2, N2, P3 and late negativity -LN) as well as behavioural responses (reaction time -RT; correct responses -CRs; and number of errors) were analyzed and then subjected to cluster analysis., Results: Both MS groups showed delayed behavioural responses and enhanced latency for long-latency ERP components (P2, N2, P3) as well as relatively preserved ERP amplitude, but BMS patients obtained more important performance deficits (lower CRs and higher RTs) and abnormalities related to the latency (N1, P3) and amplitude of ERPs (eCNV, eN1, LN). However, RRMS patients also demonstrated abnormally high amplitudes related to the preparation performance period of CNV (cCNV) and post-processing phase (LN). Cluster analyses revealed that RRMS patients appear to make up a relatively homogeneous group with moderate deficits mainly related to ERP latencies, whereas BMS patients appear to make up a rather more heterogeneous group with more severe information processing and attentional deficits., Conclusions: Our findings are suggestive of a slowing of information processing for MS patients that may be a consequence of demyelination and axonal degeneration, which also seems to occur in MS patients that show little or no progression in the physical severity of the disease over time.

Purpose: To revise the 2003 version of the American Urological Association's (AUA) Guideline on the management of benign prostatic hyperplasia (BPH)., Materials and Methods: From MEDLINE® searches of English language publications (January 1999 through February 2008) using relevant MeSH terms, articles concerning the management of the index patient, a male ≥45 years of age who is consulting a healthcare provider for lower urinary tract symptoms (LUTS) were identified. Qualitative analysis of the evidence was performed. Selected studies were stratified by design, comparator, follow-up interval, and intensity of intervention, and meta-analyses (quantitative synthesis) of outcomes of randomized controlled trials were planned. Guideline statements were drafted by an appointed expert Panel based on the evidence., Results: The studies varied as to patient selection; randomization; blinding mechanism; run-in periods; patient demographics, comorbidities, prostate characteristics and symptoms; drug doses; other intervention characteristics; comparators; rigor and intervals of follow-up; trial duration and timing; suspected lack of applicability to current US practice; and techniques of outcomes measurement. These variations affected the quality of the evidence reviewed making formal meta-analysis impractical or futile. Instead, the Panel and extractors reviewed the data in a systematic fashion and without statistical rigor. Diagnosis and treatment algorithms were adopted from the 2005 International Consultation of Urologic Diseases. Guideline statements concerning pharmacotherapies, watchful waiting, surgical options and minimally invasive procedures were either updated or newly drafted, peer reviewed and approved by AUA Board of Directors., Conclusions: New pharmacotherapies and technologies have emerged which have impacted treatment algorithms. The management of LUTS/BPH continues to evolve., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Radiotherapy induced urethral strictures are often difficult to manage due to proximal location, compromised vascular supply and poor wound healing. To determine the success of urethroplasty for radiation induced strictures we performed a multi-institutional review of men who underwent urethroplasty for urethral obstruction., Materials and Methods: A total of 30 men (mean age 67 years) underwent urethroplasty at 3 separate institutions. Excision with primary anastomosis was used in 24 of 30 patients (80%), with 4 of 30 requiring a genital fasciocutaneous skin flap and 2 a buccal graft. Hospitalization was less than 23 hours for 70% of the patients. Recurrence was defined as cystoscopic identification of urethral narrowing to less than 16Fr in diameter., Results: All strictures were located in the bulbomembranous region. Mean stricture length was 2.9 cm (range 1.5 to 7). External beam radiotherapy for prostate cancer was the etiology of stricture disease in 15 men (50%), with brachytherapy in 7 (24%) and a combination of the 2 modalities in 8 (26%). Successful urethral reconstruction was achieved in 22 men (73%) at a mean of 21 months. Mean time to stricture recurrence was 5.1 months (range 2 to 8). Two men required balloon dilation after stricture recurrence and none required urinary diversion. Incontinence was transient in 10% and persistent in 40%, with 13% requiring an artificial urinary sphincter. The rate of erectile dysfunction was unchanged following urethroplasty (47% preoperative, 50% postoperative)., Conclusions: Urethroplasty for radiation induced strictures has an acceptable rate of success and can be performed without tissue transfer techniques in most cases. Almost half of men will experience some degree of incontinence as a result of surgery but erectile function appears to be preserved., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: • To describe our experience with surgical management of transplant ureteral strictures over a 6-year period., Patients and Methods: • The present study identified patients who underwent open reconstruction for transplant ureteral strictures between March 2002 and May 2008 after kidney or kidney-pancreas transplantation. • Baseline clinical characteristics were documented, including age at transplantation and reconstruction, serum creatinine levels, immunosuppressive drug regimen, and comorbidities. • Postoperative complications were noted, including urinary tract infections, stricture recurrence and graft failure. • Successful reconstructions were defined as stable allograft function with unobstructed outflow not requiring repeat dilation, ureterotomy or stent placement., Results: • Median age at the time of reconstruction was 51 years and the mean time from transplantation was 62 months. • Seven of the 13 patients had failed previous balloon dilation. • The patients were followed for a median of 41 months and a successful repair was achieved in 10 of 13 patients. • Ureteral strictures recurred in two patients who received ureteroneocystostomies, which were subsequently managed with chronic stent exchanges. • Another recurrence involved a 1.5-cm anastomotic stricture 6 months postoperatively, which was balloon-dilated and has remained recurrence-free for 16 months., Conclusions: • Patients who present > 6 months after renal transplantation with ureteral strictures that are recalcitrant to endoscopic management can safely undergo open surgical ureteral reconstruction without subsequent renal or graft failure. • Further investigation involving a larger patient cohort is required to confirm these initial results., (© 2010 THE AUTHORS. BJU INTERNATIONAL © 2010 BJU INTERNATIONAL.)

Purpose: Numerous federal bodies and professional societies have produced guidelines and standards for the reprocessing of endoscopes, but few specifically address the reprocessing of cystoscopes., Materials and Methods: This document presents a summary of the current recommendations for reprocessing flexible cystoscopes, and highlights particular aspects of instrument reprocessing that are unique to cystoscopy., Results: Cystoscopes are classified as "semi-critical" devices. Such devices require high-level disinfection or sterilization between patients. High-level disinfection differs from sterilization in that high-level disinfection does not kill large numbers of bacterial spores, while sterilization involves the complete destruction of all microbial life. In the office setting, high-level disinfection (using glutaraldehyde or another chemical disinfectant) is commonly employed for the reprocessing of flexible cystoscopes. During high-level disinfection, standard reprocessing steps should be followed to prevent contamination of the cystoscope between uses. These include precleaning, leak testing, cleaning, disinfection, rinsing, and drying. Recommended "soak times" for glutaraldehyde vary from 20 to 45 minutes, depending upon the degree to which these steps are followed. If no precleaning is performed, a 45-minute glutaraldehyde soak is required to achieve high-level disinfection. Conversely, a 20-minute soak is adequate to achieve high-level disinfection if recommended reprocessing steps are followed prior to immersion in the glutaraldehyde. One chemical disinfectant (ortho-phthalaldehyde) has been associated with anaphylaxis in bladder cancer patients, and should be avoided in these patients., Conclusions: This white paper provides a concise reference document for the reprocessing of flexible cystoscopes. In addition, references and links to more comprehensive resources are provided. This document may be useful for clinicians and others who are in search of guidance in this area., (Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Recent research has suggested that young children have relatively well-developed trait concepts. However, this literature overlooks potential age-related differences in children's appreciation of the fundamentally dimensional nature of traits. In Study 1, we presented 4-, 5-, and 7-year-old children and adults with sets of characters and asked them to indicate the preferences of a target character who shared appearance attributes with one character (appearance match) and shared a common trait with the other character (trait match). Traits were presented in a way that emphasized either their categorical or their dimensional nature. When the dimensional nature of trait terms was emphasized, the youngest children made fewer trait-based inferences, and the use of traits increased with age. In Study 2, we gave 4-year-old children and adults the same task except that the extent to which appearance cues could serve as a meaningful basis of judgment was varied. Results were consistent with the findings of Study 1, although children were more likely to rely on dimensional presentations of traits in the absence of strong appearance cues. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Objectives: To describe the outcomes and reconstructive techniques used for men with symptomatic urethral diverticula in an attempt to standardize treatment based on the length of the urethral defect after diverticulum excision and the type of repair used. Urethral diverticula are rare in men and may be either congenital or acquired., Methods: Between 2003 and 2008, 13 men were treated surgically for symptomatic urethral diverticula at a single institution by a single surgeon (C.M.G.). A total of 6 (46.2%) patients had urethral defects of < 4 cm and underwent excision of the diverticulum with primary anastomosis. Substitution urethroplasty using either penile skin or buccal mucosa was used in 7 (53.8%) patients with urethral defects of >or= 4 cm. Demographic and preoperative characteristics were compared among patients according to the length of the urethral defect., Results: The mean age of men at the time of surgery was 38.4 years (+/- 13.0; range, 20.4-63.7), with a median follow-up time of 21.7 (+/- 29.0; range, 0.9-84.0) months. Neither age at the time of surgery, length of follow-up, or diverticulum volume was significantly different between men who underwent primary repair vs substitution urethroplasty. The overall success rate was 92% (12/13) with an overall complication rate of 42% at intermediate follow-up., Conclusions: Outcomes after excision and primary anastomosis for diverticula associated with defects of < 4 cm were similar to outcomes after diverticulum excision and substitution urethroplasty for defect of >or= 4 cm., (Copyright 2010 Elsevier Inc. All rights reserved.)

Purpose: Urethral reconstruction may improve ejaculatory function by relieving urethral obstruction but could worsen it by disrupting the bulbocavernosus muscle. We prospectively evaluated the effects of urethral reconstruction on ejaculatory function., Materials and Methods: All men who underwent anterior urethroplasty from September 2006 to June 2009 were asked to complete the ejaculatory function component of the Male Sexual Health Questionnaire (7 questions with a total of 35 points) preoperatively and postoperatively after resuming sexual activity. Postoperatively decreased and improved ejaculation was defined as an increase and a decrease of 5 or more points, respectively., Results: A total of 43 men were included in the study. The overall ejaculatory score did not change postoperatively (25.54 vs 26.94 points, p = 0.17) at a mean +/- SD followup of 8.1 +/- 6.0 months but men with poor preoperative function had significant improvement (15.27 vs 21.22 points, p = 0.01). Overall ejaculatory vigor (3.19 vs 3.56 points, p = 0.25) and volume (3.49 vs 3.88, p = 0.19) did not change significantly. Postoperative function was stable in 30 men (70%), improved in 8 (19%), including 7 with bulbar and 1 with penile urethroplasty, and worse in 5 (11%), including 4 with bulbar and 1 with penile urethroplasty., Conclusions: Urethral reconstruction appears to have a minimal effect on ejaculatory function when evaluated by the Male Sexual Health Questionnaire. More objective testing may be necessary to fully assess the effect of urethroplasty on ejaculatory function., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Buccal derived graft tissue has been proven to be useful in urethral reconstruction. However, nonbuccal sources are often needed for long segment strictures or for those with prior buccal harvest. We describe a technique using full-thickness abdominal skin grafts for long segment urethroplasty and present the short-term outcomes., Materials and Methods: A total of 21 men underwent urethroplasty for strictures of an average of 11 cm (range 4 to 24) using abdominal wall skin. Prior urethroplasty was performed in 52% of patients and multistage repair was conducted in 48%., Results: The recurrence rate following urethroplasty was 19%, with 9.5% requiring revision after first stage urethroplasty. Complications included hair from the skin graft during the early part of the series (14.5%), glans dehiscence (9.5%), urethrocutaneous fistula (9.5%) and periurethral abscess (1 patient). Histological evaluation at 6 months demonstrated excellent uptake of grafts with minimal keratinization., Conclusions: In men with significant penile scarring, lichen sclerosis and long segment urethral strictures the use of abdominal skin limits donor site morbidity, and provides a useful alternative graft source for urethroplasty when buccal mucosa or genital skin are not available or sufficient. Grafts should be harvested from nonhair bearing areas to minimize the risk of urethral hair development., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Nanomaterials are of particular interest in environmental chemistry due to their unknown toxicity to living organisms. Reports indicate that nanoparticles (NPs) affect seed germination, but the uptake and biotransformation of metal nanoparticles is not well understood. The present study investigated the toxicity and biotransformation of Ni(OH)2 NPs by mesquite plants (Prosopis sp.). Three sets of plants were treated for four weeks with 0.01, 0.05, or 0.10 g of either uncoated or sodium citrate coated NPs before and after synthesis. Nickel concentrations in plants were determined by inductively coupled plasma-optical emission spectroscopy (ICP-OES) and the form and oxidation state of Ni was determined using X-ray absorption spectroscopy (XAS). Results showed that uncoated NPs had an average size of 8.7 nm, whereas coated NPs before and after synthesis had an average of 2.5 and 0.9 nm, respectively. The ICP-OES results showed that plants treated with 0.10 g of uncoated and coated NPs before and after synthesis had 803, 764, and 400 mg Ni kg dry weight, in the leaves, respectively. The XAS analyses showed Ni NPs in roots and shoots of plants treated with uncoated NPs, whereas leaves showed a Ni(II)-organic acid type complex. However, plants treated with coated NPs before or after synthesis showed Ni NPs only in roots and a Ni(II)-organic acid complex in shoots and leaves. Results also showed that none of the treatments reduced plant size or chlorophyll production. To the authors' knowledge, this is the first time that the biotransformation of nanoparticles by a plant system is reported., (Copyright (c) 2010 SETAC.)

Background: Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners' opinions are vital to the development of future curricula., Design: Qualitative research using focus group methodology., Objectives: Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught., Participants: Study participants were first year medical students with an interest in health disparities (n = 17)., Approach: Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process., Main Results: The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities., Conclusions: While many of the students' opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.

Purpose: Anterior urethroplasty has been shown to negatively impact erectile function. Recovery of function is common but the likelihood and extent of recovery have not been fully elucidated., Materials and Methods: Between October 2006 and May 2008 men undergoing anterior urethroplasty were enrolled in a prospective study to evaluate the effects of urethroplasty on erectile function. The International Index of Erectile Function was completed preoperatively and on all subsequent postoperative visits. Preoperative and postoperative erectile function was compared., Results: A total of 52 patients who underwent anterior urethroplasty were included in the study. Repair locations were bulbar (35) and penile (17). Of the patients undergoing bulbar urethroplasty 20 had excision and primary anastomosis, and 15 had augmented anastomotic repair. All penile repairs were ventral onlay repair (11) or inlay repair in 2 stages (6). Postoperative erectile dysfunction was noted in 20 (38%) men, of whom 18 recovered fully at a mean postoperative period of 190 days (range 92 to 398). In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p = 0.05). Within the bulbar urethra excision and primary anastomosis repairs led to slightly higher erectile dysfunction rates than augmented anastomotic repairs (50% vs 26%, p = 0.16)., Conclusions: Anterior urethroplasty caused erectile dysfunction in approximately 40% of patients, although recovery was seen in most by 6 months. Bulbar urethroplasty appears to affect erectile function to a greater extent than penile urethroplasty, which may be explained by the proximity of the bulbar urethra to the nerves responsible for erection., (Copyright 2010 American Urological Association. Published by Elsevier Inc. All rights reserved.)

This paper presents a methodology for Obstructive Sleep Apnea (OSA) detection based on the HRV analysis, where as a measure of relevance PLS is used. Besides, two different combining approaches for the selection of the best set of contours are studied. Attained results can be oriented in research focused on finding alternative methods minimizing the HRV-derived parameters used for OSA diagnosing, with a diagnostic accuracy comparable to a polysomnogram. For two classes (normal, apnea) the results for PLS are: specificity 90%, sensibility 91% and accuracy 93.56%.

Objective: To examine a large, single-surgeon series of patients with prostate cancer who underwent retropubic radical prostatectomy (RRP) for men with postoperative bladder neck contractures (BNCs)., Patients and Methods: From 1983 to 2007, 4132 men underwent RRP for prostate cancer by one surgeon. All patients had BN reconstruction with mucosal eversion. The bladder to membranous urethral anastomosis was made using six 2/0 chromic catgut sutures over an 18 F Foley catheter. The catheter was left in place for 10 days. Data from these men is stored in a prospective database, which was reviewed in this study for men with BNCs after RRP. Men with BNCs were compared with all other men in the series to determine risk factors for BNC development., Results: Overall, BNCs developed in 110 patients (2.5%). Examining our last 500 patients there was a contemporary BNC rate of <1%. The median (range) follow-up was 44 (12-233) months. Tumour characteristics were similar in the men with BNCs and those with no BNCs, and the rates of organ-confined disease were also similar (65% vs 70%, P = 0.27). Men with BNCs had higher median preoperative prostate-specific antigen (PSA) levels (6.7 vs 5.7 mg/dL; P = 0.009) and were more likely to have PSA failure after RRP (30% vs 16%, P < 0.001). On multivariate analysis, non-nerve sparing (P = 0.003) and a surgical date before 1992 (P < 0.001) were significant predictors of BNC. Patients with BNCs had lower potency rates (49% vs 63%, P < 0.003) and continence rates (88% vs 94%, P = 0.07) at the 18-month follow-up., Conclusions: BNCs are rare, occurring in <1% in our modern series. The important surgical factors in preventing BNCs are to avoid closing the BN too tightly and attaining good apposition of the BN with the urethral stump with a watertight closure. BNCs are more common with non-nerve-sparing surgery and early in a surgeon's experience.

Purpose: Urethroplasty remains the gold standard for the management of urethral stricture disease with acceptable long-term success. However, the standard by which stricture recurrence is defined and evaluated after urethral reconstruction remains widely variable. We conducted a systematic review of the urological literature to determine how stricture recurrence is defined and evaluated., Materials and Methods: A systematic review was conducted on all contemporary urethroplasty articles published between 2000 and 2008. Using the term "urethroplasty" 302 articles were identified and evaluated. A total of 86 articles were included in the analysis., Results: The overall recurrence rate for all reconstructive procedures was 15.6%, which remained stable between 2000 and 2008. Stricture recurrence was determined by a mean of 3 (range 1 to 8) different diagnostic tests. The most common primary diagnostic tests for recurrence were uroflowmetry (56% of articles) and retrograde urethrography (51%). Cystourethroscopy was used as a primary screen to identify stricture recurrence in 25% of articles, and as a secondary procedure in another 21%. Recurrence was defined as the need for an additional surgical procedure or dilation in 75% and 52% of articles, respectively., Conclusions: The methods used to determine stricture recurrence after urethroplasty remain widely variable. The use of a standardized surveillance protocol to define stricture recurrence after urethral reconstruction may allow more effective comparison of urethroplasty outcomes across institutions.

Nurses and other caregivers face high risk for developing work-related musculoskeletal disorders associated with manual ambulation of patients with orthopaedic conditions. In addition to the physical demands needed to support the patient's weight during ambulation, injury risk increases if the patient falls. A task force including representatives from the National Association of Orthopaedic Nurses, American Nurses Association, National Institute for Occupational Safety and Health, and Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center in Tampa developed an ergonomic tool for determining best practices for safe ambulation of orthopaedic patients (C. A. Sedlak, M. O. Doheny, A. Nelson, & T. R. Waters, 2009). Scientific evidence, concepts of ergonomic safety, and safe patient-handling equipment were incorporated into an ergonomic tool designed to increase safety and reduce unnecessary variation in practice associated with this high-risk patient-handling task (National Institute for Occupational Safety Health, 1997; National Research Council/Institute of Medicine, 2001; A. Nelson, 2006; T. Waters, 2007).

The principles of 'lean management' have permeated many sectors of today's business world, secondary to the success of the Toyota Production System. This management method enables workers to eliminate mistakes, reduce delays, lower costs, and improve the overall quality of the product or service they deliver. These lean management principles can be applied to health care. Their implementation within the ambulatory care setting is predicated on the continuous identification and elimination of waste within the process. The key concepts of flow time, inventory and throughput are utilized to improve the flow of patients through the clinic, and to identify points that slow this process -- so-called bottlenecks. Nonessential activities are shifted away from bottlenecks (i.e. the physician), and extra work capacity is generated from existing resources, rather than being added. The additional work capacity facilitates a more efficient response to variability, which in turn results in cost savings, more time for the physician to interact with patients, and faster completion of patient visits. Finally, application of the lean management principle of 'just-in-time' management can eliminate excess clinic inventory, better synchronize office supply with patient demand, and reduce costs.

Nurses and other caregivers face high risk for developing work-related musculoskeletal disorders associated with turning (logrolling) patients with orthopaedic conditions. The task is considered high risk on the basis of weight limits and awkward positioning. A task force including representatives from the National Association of Orthopaedic Nurses the American Nurses Association, the National Institute for Occupational Safety and Health, the Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center in Tampa, Diligent Services, and Guldmann, Inc., developed an ergonomic tool for determining best practices for safe patient turning. Scientific evidence, concepts of ergonomic safety, and safe patient handling equipment were incorporated into this ergonomic tool.

Nurses and other caregivers face high risk for developing work-related musculoskeletal disorders while lifting and holding limbs in the orthopaedic practice setting. A task force including representatives from the National Association of Orthopaedic Nurses, American Nurses Association, National Institute for Occupational Safety and Health, Patient Safety Center of Inquiry at the James A. Haley Veterans Administration Medical Center in Tampa, Diligent Services, and Guldmann, Inc., developed an orthopaedic clinical tool for determining maximum recommended weight limits for lifting and holding arms and legs for treatment of the orthopaedic patient. Scientific evidence, concepts of ergonomic safety, and safe patient-handling equipment were incorporated into this clinical tool.

Objective: To describe the surgical outcomes and operative technique for reconstructing catheter-induced urethral erosion in men with a neurogenic bladder., Patients and Methods: This was a prospective study of 11 men (median age 45 years, range 26-52) who had elective urethroplasty for urethral erosion between 2004 and 2007 by one surgeon (C.M.G.). All men had a diagnosis of neurogenic bladder and indwelling catheter-induced urethral erosion. Reconstructive techniques included primary closure in six men, substitution urethroplasty with a penile skin graft in three, penile skin flap in one and a buccal mucosa graft in one. A two-stage approach was used in one man., Results: The median (range) length of erosion from the meatus before surgery was 6 (4-10) cm. The repair was successful in seven men at a mean (range) follow-up of 25 (8-46) months. Of those with recurrence of erosion, the median length of the resultant defect was 2 (2-3) cm. All recurrences were in the first five patients of this series. The median time to recurrence of erosion was 1 month and recurrence did not appear to be related to any particular surgical technique. Urethral catheter traction after surgery appeared to be one of the factors related to repair breakdown., Conclusion: The reconstruction of catheter-induced urethral erosion in men with a neurogenic bladder is feasible. Primary closure appears to be the best reconstructive method for urethral erosion, and avoiding catheter traction after surgery contributes to successful urethroplasty.

Purpose: Reconstruction of long segment urethral stricture disease in adults with a history of pediatric hypospadias repair remains complex secondary to poor urethral blood supply, extensive penile scarring and the need for significant amounts of graft or flap tissue. We describe our experience with staged urethroplasty in this cohort of men., Materials and Methods: A total of 15 males underwent staged urethroplasty for urethral stricture disease following previous hypospadias repair in childhood. All men underwent 2-stage repair with a minimum of 6 months separating each operation. Bulbar urethral stricture disease due to previous dilation was seen in 2 of the 15 men (14%). Graft sources included buccal mucosa in 12 cases, full-thickness hairless abdominal wall skin in 2, penile skin in 1 and posterior auricular tissue in 1., Results: Median patient followup was 22 months (range 5 to 62) after stage 2 closure. Median patient age at presentation was 31 years (range 19 to 57). Mean stricture length was 8 cm (range 5 to 14) and mean graft area was 22 cm(2) (range 10 to 38). There was no clinical evidence of stricture recurrence, fistula or wound dehiscence at last followup in 13 of the 15 men (86%). Two men with a congenital hypoplastic glans were left with distal hypospadias. Minor voiding symptoms were described in 3 of the 15 men (21%) with resolution in all by 6 months postoperatively., Conclusions: We describe outcomes after staged reconstruction for extensive urethral stricture disease in men after previous pediatric hypospadias repair in childhood. At intermediate followup staged urethroplasty provided acceptable outcomes.

Neuregulin-1 (NRG-1) is genetically linked with schizophrenia, a neurodevelopmental cognitive disorder characterized by imbalances in glutamatergic and dopaminergic function. NRG-1 regulates numerous neurodevelopmental processes and, in the adult, suppresses or reverses long-term potentiation (LTP) at hippocampal glutamatergic synapses. Here we show that NRG-1 stimulates dopamine release in the hippocampus and reverses early-phase LTP via activation of D4 dopamine receptors (D4R). NRG-1 fails to depotentiate LTP in hippocampal slices treated with the antipsychotic clozapine and other more selective D4R antagonists. Moreover, LTP is not depotentiated in D4R null mice by either NRG-1 or theta-pulse stimuli. Conversely, direct D4R activation mimics NRG-1 and reduces AMPA receptor currents and surface expression. These findings demonstrate that NRG-1 mediates its unique role in counteracting LTP via dopamine signaling and opens future directions to study new aspects of NRG function. The novel functional link between NRG-1, dopamine, and glutamate has important implications for understanding how imbalances in Neuregulin-ErbB signaling can impinge on dopaminergic and glutamatergic function, neurotransmitter pathways associated with schizophrenia.

Purpose: In patients with solid organ transplants urethral strictures may develop from repeat catheterization, recurrent urinary tract infection or chronic irritation of the urethral mucosa secondary to contact with pancreatic enzymes. We describe surgical outcomes in patients with kidney and kidney-pancreas transplants after urethral reconstruction for stricture or fistula disease., Materials and Methods: Ten males underwent urethroplasty for urethral stricture (9) or urethral fistula (1) disease after kidney or kidney-pancreas transplantation. Median patient age was 41.5 years (range 25 to 56) and average time from transplantation was 9 years (range 1 to 14). Four patients underwent bulbar urethroplasty with buccal mucosa, 3 underwent stricture excision and primary anastomosis of the bulbar urethra, 2 underwent penile urethroplasty with graft tissue and 1 underwent bulbar urethrocutaneous fistula repair., Results: The etiology of stricture disease was pancreatic enzyme induced stricture in 40% of cases, catheter trauma in 40% and unknown in 20%. Nine of 10 patients (90%) were free of symptoms and recurrence at a median followup of 32.5 months (range 4 to 83). One patient who required cystoscopy and dilation for a bulbar urethral recurrence is currently disease-free. Postoperative morbidity included urinary tract infection and a perineal hematoma requiring transfusion., Conclusions: We describe the outcomes of urethral reconstruction in patients with kidney and kidney-pancreas transplantation. As in men with normal native kidney and pancreas function, urethroplasty appears to be safe and effective in this cohort. Long-term outcome data are needed to confirm these findings.

Multiple tissue sources have been used for urethral reconstruction in adults. Patients with lichen sclerosis (LS), long segment strictures, or prior oral graft use have less available tissue for urethroplasty. We describe a technique for the use of a full-thickness skin graft of hairless abdominal skin for long segment urethroplasty.

Purpose: We present a single institutional experience over 6 years of intra and postoperative complications following urethral reconstructive surgery, and the impact of these complications on overall results., Materials and Methods: From June 2000 through May 2006, 153 consecutive urethral reconstructive procedures were performed on 128 patients by one surgeon (CMG). Complication rates were determined, and subgroups were categorized based on stricture etiology, patient age, length of stricture, location of stricture, type of repair, and presence of various co-morbid conditions., Results: Overall, 23 of 153 cases (15%) had an intra or postoperative complication with a mean follow-up time of 28.3 months (range 3 to 74). The most common complications were related to infection (n = 9). Other complications included repair breakdown (n = 4), bleeding (n = 4), fistulae (n = 3), thromboembolic (n = 2), positioning-related (n = 2), and Foley catheter malfunction (n = 1). Complication rates for anastomotic and substitution urethroplasty were 9.1% (4/44) and 17% (19/109), respectively. The number of patients with at least one year of follow-up who had a complication and eventual stricture recurrence was 20% (4/20), while only 7.4% (7/95) of those who did not have a complication recurred (p = 0.08)., Conclusions: Complications following reconstructive surgery for urethral stricture disease were mostly related to infection or repair breakdown in the immediate postoperative period. It does not appear that an intra or postoperative complication following urethral reconstructive surgery impacts the chance of eventual stricture recurrence at intermediate follow-up.

Purpose: There is limited literature examining urethral reconstruction in patients with neurogenic bladder dysfunction. We describe our experience of urethral reconstruction in men with concurrent neurogenic bladder., Materials and Methods: A prospectively maintained database of all urethral reconstruction procedures performed by 1 surgeon was analyzed for patients with neurogenic bladder dysfunction. Patient characteristics including the etiology of neurogenic bladder, urethral pathology, urethral reconstructive technique, complications and recurrences were evaluated., Results: A total of 23 patients were included in the analysis. Urethral pathology included erosions (10), strictures (7), diverticula (3), urethrocutaneous fistulas (2), and a combination of diverticular and stricture disease (1). Median length of the urethral pathology was 5.0 cm (range 2.0 to 10.0). Overall urethral reconstruction was successful in 16 of 23 patients (69.6%) at a mean followup of 24.7 months (range 2 to 79). Success rates differed among the types of pathology with 60% for urethral erosions, 85.7% for urethral strictures, and 66.6% for urethral diverticula and fistulas. Of those cases of recurrence 4 of 7 (57%) were after urethral erosion repair. There was 1 (4.3%) postoperative complication and no patient underwent urinary diversion after recurrence., Conclusions: When identified at an early stage, urethral reconstruction in patients with neurogenic bladder dysfunction offers acceptable outcomes with limited morbidity. Men undergoing reconstruction for urethral erosion had inferior outcomes compared to those with other urethral pathology.

Objective: To examine the prevalence and management of urinary incontinence (UI) and their impact on self-reported health in the U.S. Medicare managed care beneficiaries., Methods: Data were from the 2003 Medicare Health Outcomes Survey Cohort VI Baseline. Only beneficiaries aged 65 years or older and who self-completed the telephone interview were included., Results: About 37% of the study sample (N = 82,196) reported having accidental urine leakage (the UI group). A total of 75% of the UI group indicated UI's being a problem and 41% of them had spoken with a doctor about it. Of these, 50% had received treatment. The findings indicate the UI group generally had significantly worse SF-36 Survey Scale scores than the non-UI group with and without adjusting other covariates., Discussion: UI is prevalent but undertreated as it adversely affects many health domains in this population. This study highlights the need for early detection, proper education, and access to effective treatment options for UI in the elderly.

Objectives: Electronic medical records (EMRs) have been proposed as technology through which the quality of healthcare could be improved. We present an analysis of the cost and productivity implications associated with the transition from transcription to an EMR system in an ambulatory setting., Methods: Data were collected from eight consecutive fiscal years from 1998 to 2005. Transcription was used in the first 4-year period, and EMR was implemented and used in the later 4-year period. Productivity was defined as ambulatory revenue and the number of patient encounters. All costs related to transcription and EMR implementation were calculated. All data were adjusted for inflation., Results: Within the transcription era, the transcription costs were $395,404, total revenue was $18,137,945, and patient encounters numbered 52,027. The average transcription cost per encounter was $7.60, average revenue per encounter was $348.63, and average revenue per provider was $505,615. Within the EMR era, the EMR-related costs were $293,406, total revenue was $30,370,647 and patient encounters numbered 65,102. The average documentation cost per encounter was $4.51, average revenue per encounter was $466.51, and average revenue per provider was $690,242. The startup costs of initial EMR implementation were $10,329 per physician provider., Conclusions: The results of our study have shown that the implementation of an EMR system when an economy of scale exists coincides with an increase in the revenue per encounter and per provider compared with transcription. The advantage of the fixed costs of an EMR system compared with the variable costs of a transcription-based system is the allowance of cash savings in an ambulatory surgical subspecialty practice.

People make social inferences without intentions, awareness, or effort, i.e., spontaneously. We review recent findings on spontaneous social inferences (especially traits, goals, and causes) and closely related phenomena. We then describe current thinking on some of the most relevant processes, implicit knowledge, and theories. These include automatic and controlled processes and their interplay; embodied cognition, including mimicry; and associative versus rule-based processes. Implicit knowledge includes adult folk theories, conditions of personhood, self-knowledge to simulate others, and cultural and social class differences. Implicit theories concern Bayesian networks, recent attribution research, and questions about the utility of the disposition-situation dichotomy. Developmental research provides new insights. Spontaneous social inferences include a growing array of phenomena, but they have been insufficiently linked to other phenomena and theories. We hope the links suggested in this review begin to remedy this.

Purpose: The superiority of silicone over latex based catheters following urethral reconstructive surgery for stricture disease has been theorized, and yet data comparing their use in this group of patients are lacking. We present our findings from a prospective, randomized trial comparing silicone to hydrogel coated latex catheters in patients following urethral reconstructive surgery., Materials and Methods: From February 2004 to August 2006 men undergoing urethral reconstructive surgeries were randomized to receive an all-silicone or a hydrogel coated latex urethral catheter for postoperative bladder drainage. Patient demographics and the various reconstructive procedures used were analyzed. Complications and stricture recurrence were evaluated in the 2 groups., Results: A total of 85 men were randomized to receive a silicone (43) or a latex (42) catheter following reconstructive surgery. Median followup was 20 months (range 10 to 36). Mean patient age, urethral stricture length, complication rate and type of reconstructive procedure did not significantly differ between the 2 groups. Five patients (11%) per group required repeat instrumentation for stricture recurrence (p = 0.97). Median time to stricture recurrence was not statistically different between the 2 groups., Conclusions: The theoretical benefit of silicone catheters over hydrogel coated latex catheters does not appear to translate into a clinical advantage after urethral reconstructive surgery since we found no difference in the rate of recurrence or operative complications at intermediate term followup. It appears that the 2 types of catheter are appropriate for urethral stenting following urethral reconstructive surgery.

Introduction and objective. We examined patient waiting times, physician utilization, and exam room utilization in order to identify process improvements that may improve patient satisfaction. Methods. Time patient arrived to clinic, time patient was placed in the exam room, time the physician arrived in the exam room, and time physician discharged the patient from the exam room were prospectively recorded for 226 outpatient visits. Results. Overall, 63.2% of patients were on time for their scheduled appointment with 14.8% patient "no-shows." On-time patients were found to have a longer wait time once in the exam room for the physician than those that were late (14.8 +/- 9.2 minutes versus 11.0 +/- 8.4 minutes, P = .005); however, those patients spent a significantly longer time with the physician (10.7 +/- 6.0 minutes versus 8.9 +/- 5.8 minutes, P = .041). Exam room utilization was lower for late patients (28.9% versus 44.7%, P = .03) with physician utilization lower in clinics with 3 or more late patients when compared to clinics with 2 or fewer (59.7% versus 68.7%, P = .004). Conclusions. Late patients had significantly less time with the physician than on-time patients. Late patients also decreased the overall efficiency of the clinic; therefore, measures to reduce late patients are vital to improve clinic efficiency.

Purpose: Pay for performance represents a new paradigm for physician reimbursement based on the value based purchasing of health care services. Government and private payers have expressed an interest in moving toward this system with several pay for performance programs already in place. The rationale behind this initiative and what it means for the practicing urologist are discussed., Materials and Methods: MEDLINE and Internet based research focusing on the topics of health care quality, measures used to implement pay for performance, and private and public sector experience with pay for performance to date were reviewed., Results: Health care quality can be assessed through 3 types of measures, including structure, process and outcome. Structure measures involve the environment where services are provided, whereas process measures capture how a particular provider delivers health care. Outcome assessment involves the results of the services provided. These measures are best used when they are used in coordination with each other, and when they are risk adjusted. Most pay for performance systems in use today are based on these measures. However, there are little data that show whether this reimbursement paradigm actually improves the quality of heath care provided., Conclusions: Many questions remain regarding the implementation of a pay for performance system in the field of urology. Government and private payers are motivated to implement pay for performance. However, specific evidence based metrics for urology that fairly and accurately define quality are currently lacking. Given that implementation of a nationwide pay for performance system appears to be inevitable, urology involvement in the development and implementation of these health care quality metrics is essential.