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Viruses acquire host genes via horizontal transfer and can express them to manipulate host biology during infections. Some homologs retain sequence identity, but evolutionary divergence can obscure host origins. We use structural modeling to compare vaccinia virus proteins with metazoan proteomes. We identify vaccinia A47L as a homolog of gasdermins, the executioners of pyroptosis. An X-ray crystal structure of A47 confirms this homology, and cell-based assays reveal that A47 interferes with caspase function. We also identify vaccinia C1L as the product of a cryptic gene fusion event coupling a Bcl-2-related fold with a pyrin domain. C1 associates with components of the inflammasome, a cytosolic innate immune sensor involved in pyroptosis, yet paradoxically enhances inflammasome activity, suggesting differential modulation during infections. Our findings demonstrate the increasing power of structural homology screens to reveal proteins with unique combinations of domains that viruses capture from host genes and combine in unique ways., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: There is a lack of data on the natural history of asymptomatic intrarenal calculi. In this study, we investigate stone-related events (SREs) in patients with untreated intrarenal calculi. We also investigate predictive factors for SREs. Methods: All patients found with an asymptomatic intrarenal calculus on CT kidney, ureter, bladder managed conservatively with interval imaging for ≥6 months were included. Patients were evaluated for any SRE. The rate of event according to calculus size, location, and number of calculi was also analyzed. Multivariate logistic regression analysis was performed to determine significant predictors for SREs. Results: In total, 266 renal units from 177 patients met inclusion criteria. The mean stone size was 4.44 mm (range 1-25 mm). Duration of follow-up was 43.78 ± 26.86 months (range 6-106 months). The overall rate of SREs, including intervention ( n  = 80) and spontaneous stone passage after ureteral colic ( n  = 40), was 45.1% ( n  = 120/266). Stones >5 mm were more likely to lead to an event compared with stones ≤5 mm (odds ratio [OR]: 2.94; p  = 0.01). Interpolar stones and stones located in multiple calices were more likely to cause a SRE than lower pole stones (OR: 2.05; p  = 0.05 and OR: 2.29; p  = 0.03, respectively). Conclusion: In this large series of patients with asymptomatic intrarenal calculi, the incidence of a spontaneous SRE was 45.1% after 41 months. Stone size and stone location were significant predictors for a SRE. Information from this study will enable urologists to accurately risk stratify patients with asymptomatic renal stones.

Purpose: This study aims to comparatively evaluate clinical outcomes of mini-PCNL and FURS for treating urinary tract calculi in a single session., Methods: A systematic search using electronic databases was performed for studies comparing mini-PCNL and FURS for the treatment of urinary tract calculi. The primary outcome measurements were stone-free rates (SFRs) and complication rates for both techniques. Secondary outcome measurements were to compare patient demographics, operative duration, and inpatient stay. Meta-analysis was performed with Review Manager version 5.3 software., Results: Sixteen studies on 1598 patients (n = 877 for mini-PCNL and n = 721 for FURS) met inclusion criteria. Demographics including age (p = 0.26), body mass index (BMI) (p = 0.51), and gender ratio (p = 0.6), were similar in both groups. Overall, SFR was significantly greater in the mini-PCNL group compared to the FURS group (n = 763/877, 89.3 ± 8.4% versus n = 559/721, 80.1 ± 13.3% [OR 2.01; 95% CI 1.53-2.64; p < 0.01]). Duration of inpatient stay was significantly greater in the mini-PCNL group compared to the FURS group (n = 877, 4 ± 1.6 days versus n = 721, 2.5 ± 2.2 days, respectively [WMD: 1.77; 95% CI 1.16-2.38, p < 0.01]. Overall complication rates were not significantly different between mini-PCNL and FURS (n = 171/877, 19.5 ± 19.1% versus n = 112/721, 15.5 ± 18.9%, respectively [OR 1.43; 95% CI 0.85-2.4, p = 0.18])., Conclusions: Mini-PCNL is associated with greater SFRs and longer inpatient stay compared to FURS. Complication rates were similar for both techniques. The advantages and disadvantages of both technologies should be familiar to urologists and conveyed to patients prior to urological intervention for nephrolithiasis.

Purpose: Data assessing the effectiveness of single-use flexible ureteropyeloscopy (FURS) are limited. This study evaluates and compares single-use FURS with conventional reusable FURS., Methods: A systematic search using electronic databases (Pubmed and Embase) was performed for studies evaluating single-use FURS in the setting of urinary tract stone disease. Outcome measures included a comparative evaluation of their mechanical, optical and clinical outcomes., Results: Eleven studies on 466 patients met inclusion criteria. In vitro comparative data were available on three single-use flexible ureteropyeloscopes (LithoVue™, Polyscope™ and SemiFlex™) and clinical data were available on two (LithoVue™ and Polyscope™). The overall stone-free rate and complication rate associated with single-use FURS was 87 ± 15% and 9.3 ± 9%, respectively. There were no significant differences in procedure duration, stone size, stone clearance and complication rates when single-use FURS and reusable FURS were compared (duration: 73 ± 27 versus 74 ± 13 min, p = 0.99; stone size: 1.36 ± 0.2 versus 1.34 ± 0.18 cm, p = 0.93; stone-free rate: 77.8 ± 18 versus 68.5 ± 33%, p = 0.76; complication rate 15.3 ± 10.6 versus 15 ± 1.6%, p = 0.3)., Conclusions: Single-use FURS demonstrates comparable efficacy with reusable FURS in treating renal calculi. Further studies on clinical efficacy and cost are needed to determine whether single-use FURS will reliably replace its reusable counterpart.

Introduction: Since the advent of prostate-specific antigen (PSA)-based testing, transrectal ultrasound (TRUS)-guided prostate biopsy has become a standard part of the diagnostic pathway for prostate cancer (PCa). Rectal bleeding is one of the common side effects of this transrectal route. While rectal bleeding is usually mild and self-limiting, it can be life-threatening. In this article, we examine rectal bleeding post-TRUS-guided prostate biopsy and explore the literature to evaluate techniques and strategies aimed at preventing and managing this common and important complication., Methods: A PubMed literature search was carried out using the keywords "transrectal-prostate-biopsy-bleed." A search of the bibliography of reviewed studies was also conducted. Additionally, papers in non-PubMed-listed journals of which the authors were aware were appraised., Results: Numerous modifiable risk factors for this bleeding complication exist, particularly anticoagulants/antiplatelets and the number of core biopsies taken. Successfully described corrective measures for such rectal bleeding include tamponade (digital/packs/catheter/tampon/condom), endoscopic sclerotherapy/banding/clipping, radiological embolization, and surgical intervention., Conclusions: We advocate early consultation with the colorectal/gastroenterology and interventional radiology services and a progressive, stepwise approach to the management of post-biopsy rectal bleeding, starting with resuscitation and conservative tamponade measures, moving to endoscopic hemostasis ± radiological embolization ± transanal surgical methods. Given the infrequent but serious nature of major rectal bleeding after TRUS biopsy, we recommend the establishment of centralized databases or registries forthwith to prospectively capture such data. To the best of our knowledge, this is the first comprehensive look specifically at the management of post-TRUS biopsy rectal bleeding.

Background: The urinary bladder and urethra comprise the lower urinary tracts. Pathological conditions that affect both structures necessitate reconstructive urological intervention with autologous tissue sources that cause neuromechanical and metabolic complications. Stem-cell therapies may offer an attractive alternative as they can replicate important host derived cellular functions such as mitosis, proliferation, differentiation and apoptosis., Objective: To provide an overview on the application of stem cell therapies for regenerating the lower urinary tracts and to discuss factors that need to be addressed before stem-cells can be reliably introduced into clinical urological practice., Results: Advantages of stem cells in reconstructive urology are their ability to self-renew and their durability. Mesenchymal stem cells (MSCs), embryonic stem cells (ESCs) and adult stem cells (ASCs) demonstrate excellent urological regenerative properties. Repairing defective lower urinary tract structures with various stem-cell derived therapies has been widely reported with encouraging results in vitro and in pre-clinical in vivo trials. Ethical considerations, cost, regulation, manufacturing and reimbursement need to be fully transparent before stem-cells are routinely applied to urological patients. International collaboration with consensus guidelines should be considered to facilitate standards that allow safe use of stem-cell therapies in urology., Conclusion: Stem cells therapies in urology are developing rapidly with many important achievements to date. Despite promising in vitro and pre-clinical data; implementation of stem cells into daily urological practice is not imminent. Further investigation is required to determine whether stem-cells will provide better clinical outcomes than current urological tissue replacement strategies., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Autologous gastrointestinal tissue is the gold standard biomaterial for urinary tract reconstruction despite its long-term neuromechanical and metabolic complications. Regenerative biomaterials have been proposed as alternatives; however many are limited by a poor host derived regenerative response and deficient supportive elements for effective tissue regeneration in vivo. Urological biomaterials are sub-classified into xenogenic extracellular matrices (ECMs) or synthetic polymers. ECMs are decellularised, biocompatible, biodegradable biomaterials derived from animal organs. Synthetic polymers vary in chemical composition but may have the benefit of being reliably reproducible from a manufacturing perspective. Urological biomaterials can be 'seeded' with regenerative stem cells in vitro to create composite biomaterials for grafting in vivo. Mesenchymal stem cells are advantageous for regenerative purposes as they self-renew, have long-term viability and possess multilineage differentiation potential. Currently, tissue-engineered biomaterials are developing rapidly in regenerative urology with many important clinical milestones achieved. To truly translate from bench to bedside, regenerative biomaterials need to provide better clinical outcomes than current urological tissue replacement strategies.

Introduction: The incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries., Methods: A prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data., Results: The incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100)., Conclusions: Current forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design., Competing Interests: Competing interests: The authors report no competing personal or financial interests.

Purpose: Data on urethral catheter related injuries are sparse. To highlight the dangers inherent in traumatic urethral catheterization we prospectively monitored the incidence, cost and clinical outcomes of urethral catheter related injuries., Materials and Methods: This prospective study was performed during a 6-month period at 2 tertiary referral teaching hospitals. Recorded data included method and extent of urethral catheterization injury, setting and time of injury, number of catheterization attempts, urological management provided, additional bed days due to urethral injury and clinical outcomes after followup. The additional cost of managing urethral injuries was also calculated., Results: A total of 37 iatrogenic urethral injuries were recorded during the 6-month period. The incidence of traumatic urethral catheterization was 6.7 per 1,000 catheters inserted. Thirty (81%) patients sustained a complication Clavien-Dindo grade 2 or greater. The additional length of inpatient hospital stay was 9.4 ± 10 days (range 2 to 53). Of these patients 9 (24%) required an indwelling suprapubic catheter and 8 (21%) have an indwelling transurethral catheter. In addition, 9 (24%) are performing self-urethral dilation once weekly and 4 (11%) have required at least 1 urethral dilation due to persistent urethral stricture disease. The additional cost of managing iatrogenic urethral injuries was €335,377 ($371,790)., Conclusions: Iatrogenic urethral catheterization injuries represent a significant cost and cause of patient morbidity. Despite efforts to educate and train health care professionals on urethral catheterization insertion technique, iatrogenic urethral injuries will continue to occur unless urinary catheter safety mechanics are altered and improved., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Radical nephrectomy (RN) is an independent risk factor for the development of chronic kidney disease (CKD) in those with renal cell carcinoma (RCC). We aimed to examine the pattern of change in post-operative renal function in patients who underwent RN for RCC over a 3 year period at our institution. We performed a retrospective review of histological and biochemical findings in patients undergoing RN for RCC over a 38 month period. Estimated glomerular filtration rate (eGFR) was recorded pre- and post-operatively and at follow-up. We analysed data on 131 patients (median follow-up 24 months). The proportion of patients with advanced CKD increased significantly at follow-up with 48 (85.7%) patients, classified as having stage 2 CKD pre-operatively, being re-classified as stage 3-5. Mean eGFR was significantly lower pre-operatively (76.6 mL/min/1.73 m2) compared to hospital discharge (61 mL/min/1.73 m2, p < 0.001) and follow-up (55.5 mL/min/1.73 m2, p < 0.001). Those with pT1 tumours sustained a significantly greater decline in eGFR compared to other stages. In conclusion, patients with pT1 a and pT1 b tumours sustain a disproportionate decline in renal function and may benefit the most from NSS.

Introduction: Men with symptoms suggestive of prostate cancer are now directly referred by their general practitioners to rapid access prostate assessment clinics (RAPACs). This service implements recommendations outlined by the National Cancer Control Programme. The RAPAC was introduced at Galway University Hospital, Galway, Ireland in June 2009, aiming to structure GP referral of patients with suspected prostate cancer to a urology service., Aims: The aims of this study are to assess our initial experience with particular emphasis on access times, patient demographics, detection rates and treatment outcomes., Methods: Data on all patients presenting to the RAPAC during the preliminary 2-year period have been gathered prospectively and analysed using standard parametric analysis methods., Results: A total of 1,106 patients were reviewed at 278 clinic sessions during the initial 2-year period. The average waiting time to first clinic visit was 18 days (12-39 days). The mean age of referral to the clinic is 65 years (44-88 years). The mean PSA is 16.31 g/dL (0.4-845 g/dL). Of the 1106 patients undergoing TRUS biopsies, 503 (45.5 %) patients were diagnosed with prostate cancer. Further analysis patient demographics and cancer grading is presented in the article. Seventy-one patients (14.1 %) underwent radical retropubic prostatectomy. Sixty-seven patients (13.3 %) are being followed on an active monitoring programme, whilst 235 (56.7 %) received primary treatment with external beam radiotherapy and 68 (13.5 %) received brachytherapy., Conclusion: This data highlight the necessity of a RAPAC to streamline the provision of prostate cancer services in the west of Ireland.

Background: Traditionally, the incidence of testicular cancer (TCa) has shown a remarkable geographical variation., Aims: To examine whether the rates of TCa varied within Ireland itself and to find possible explanations for any observations made., Methods: We observed the incidence of TCa in counties in Ireland between January 1994 and December 2007. The rate of cryptorchidism over the same time was calculated. Incidence of TCa by socio-economic status was reviewed. The role of environmental pollutants was explored. We analysed teenage obesity data as a risk factor for the development of TCa in adulthood., Results: Cork had a significantly higher rate of TCa than any other county in Ireland. Cork also had high rates of cryptorchidism, but interestingly not the highest nationwide. In Cork County specifically, least deprived areas had significantly higher rates of TCa. Organic pollutants previously linked to the development of TCa have been identified in large industries located only in Cork. Teenage obesity rates in Cork were not higher than elsewhere., Conclusions: There is a higher incidence rate of TCa in Cork than any other county. High rates of cryptorchidism alone cannot explain this. There appears to be a link with higher socio-economic status and possibly industrial pollutants. The association between sedentary lifestyle and the development of TCa is unproven.

Background/aims: Unilateral ureteral obstruction (UUO) results in renal injury. Studies report increased injury indices in male rats following UUO. Our study examined whether this gender-based renal response to UUO was reflected in sustained differences following relief of obstruction., Methods: Adult male/female rats (200-400 g) were subjected to either sham surgery (S/RN) or UUO (UUO/RN). At 24 h, obstruction was relieved and all animals underwent contralateral nephrectomy. Five days after initial surgery, animals were placed in metabolic cages and given water ad libitum for 24 h followed by a 24-hour period of complete water restriction. On day 7, animals were euthanized and samples harvested. Tubular injury, urinary volume/osmolality, creatinine clearance, plasma arginine vasopressin, renal medullary V2 receptor and aquaporin 2 (AQP2) expression were measured., Results: Male UUO/RN rats showed increased renal apoptotic injury and reduced creatinine clearance rates (glomerular filtration rate) vs. females. No gender-dependent differences were observed in urinary osmolality or concentrating ability. AQP2 expression increased post-obstruction., Conclusion: Increased injury in males following UUO remains manifest during early recovery after release of obstruction. Despite this, the grade of postobstructive diuresis is not significantly altered between sexes. This may reflect reduced glomerular filtration rate and elevated AQP2 in male rats., (Copyright (c) 2010 S. Karger AG, Basel.)

This investigation examined antecedents associated with support for clean indoor air policies. Participants (N = 550) living in a Midwestern county (population = 62,223) were randomly sampled. Results suggest that beliefs in the health risks associated with secondhand smoke are positively associated with favorable attitudes toward clean indoor air policies, whereas trait reactance is negatively associated with these attitudes. Findings also indicate that risks and trait reactance are indirectly associated with support for clean indoor air policies, mediated through anger arousal toward exposure to secondhand smoke. In addition, regression analyses revealed that health risks, trait reactance, and smoking status explained a significant amount of variance regarding anger toward exposure to secondhand smoke, but only health risks and smoking status accounted for a significant amount of variance toward clean indoor air attitudes. Finally, the Smoking Status x Health Risks interaction was supported for anger toward exposure to secondhand smoke and favorable attitudes toward clean indoor air policies. Our findings suggest the incorporation of anger appeals when promoting clean indoor air policies.

Background: Referrals to Urology OPD of men with a likely diagnosis of BPH are common., Aims: To review referrals to OPD of men with lower urinary tract symptoms (LUTS) to establish how many could have been managed without specialist assessment., Methods: We reviewed records of 200 male patients referred to OPD with LUTS. We assessed whether the referral source had performed digital rectal examination (DRE), International Prostate Symptom Score (IPSS), Bother Score or PSA level., Results: 74% of patients were referred by GPs. In 31.5% of cases DRE was performed prior to referral. One GP had completed an IPSS, none a Bother Score. 96% had a PSA checked before OPD. Ultimately, 88.5% of our patients were diagnosed with BPH., Conclusions: With better pre-assessment in the form of DRE, IPSS and Bother Score, allied to a PSA check, many patients with LUTS could be managed in a primary care setting.

Background: Follow-up of patients with an initial negative prostate biopsy, but surrounding whom a suspicion of prostate cancer persists, is difficult. In addition, debate exists as to the optimal technique for repeat prostate biopsy., Aims: To assess the cancer detection rate on repeat prostate biopsy., Methods: We reviewed patients who underwent prostate biopsy in our department in 2005 who had >or=1 previous biopsy within the preceding 5 years. Cancer detection rate on repeat biopsy and the influence of the number of biopsy cores were recorded., Results: Cancer detection rate on repeat biopsy was 15.4%, with approximately 60% detected on the first repeat biopsy, but approximately 10% not confirmed until the fourth repeat biopsy. Gleason score was similar regardless of the time of diagnosis (6.1-6.5). Mean interval between first biopsy and cancer diagnosis (range 18-55 months) depended on the number of repeat procedures. There was an association between the number of biopsy cores and cancer detection., Conclusions: This study supports the practice of increasing the number of cores taken on initial and first repeat biopsy to maximise prostate cancer detection and reduce the overall number of biopsies needed.

E-cadherin expression in the kidney is used as a surrogate marker of epithelial mesenchymal transition for the testing of various antifibrotic strategies. Here we reexamined E-cadherin expression in the kidneys of rats with unilateral ureteric obstruction, which was previously reported to decrease in parallel with the development of tubulointerstitial disease in this widely used experimental model of renal fibrosis and epithelial mesenchymal transition. E-cadherin mRNA expression was consistently increased both acutely (hours) and chronically (days) in the ligated kidney compared to the cognate non-ligated kidney. Increased E-cadherin protein levels were also found in the ligated kidney particularly in dilated tubular segments. Simulation of early pressure changes in the ligated kidney by mechanical stretch of human renal epithelial cells in culture did not alter E-cadherin expression. Porcine LLCPK-1 cells subjected to hypotonic stretch, however, did have increased E-cadherin mRNA and protein levels, responses that were not prevented by transforming growth factor-beta, a cytokine that promotes epithelial mesenchymal transition. Our findings question the utility of E-cadherin as a marker of epithelial mesenchymal transition in this model of renal fibrosis.

Background: Carotid endarterectomy (CEA) is a well-established method of stroke prevention in patients with symptomatic, high-grade internal carotid artery stenosis., Aims: To assess the change in carotid surgery practice in health board regions in Ireland over two different time periods in the past 11 years (1996-1998/2001-2003)., Methods: Numbers of discharges of patients with a procedure code CEA (38.12) between 1996-1998 and 2001-2003 were obtained from the Hospital In-Patient Enquiry (HIPE) database maintained by the Economic and Social Research Institute (ESRI). Population data was obtained from national censuses., Results: There has been considerable change in the level of carotid surgery activity in specific health board regions between the two periods., Conclusions: Still no region comes close to achieving levels of CEA recommended by population studies. This is important in the context of the MRC asymptomatic carotid surgery trial (ACST), as the numbers suitable for CEA will probably increase further in the future.

Tubular mechanical stretch is the key primary insult in obstructive nephropathy. This review addresses how the renal tubular epithelium senses and responds to mechanical stretch. Using data from renal and nonrenal systems, we describe how sensing of stretch initially occurs via the activation of ion channels and subsequent increases in intracellular calcium levels. Calcium influxes activate a number of adaptive and proinjury responses. Key among these are 1) the activation of Rho, consequent cytoskeletal rearrangements, and downstream increases in focal adhesion assembly; and 2) phospholipase activation and resultant mitogen-activated protein kinase activation. These early signaling events culminate in adaptive cellular coupling to the extracellular matrix, a process termed the cell strengthening response. Direct links can be made between increased expression of genes involved in the development of obstructive nephropathy and initial sensing of mechanical stretch. The review illustrates the repercussions of mechanical stretch as a renal stress stimulus, specific to ureteric obstruction, and provides an insight into how tubular responses to mechanical stretch are ultimately implicated in the development of obstructive nephropathy.

Background: Out-patient non-attendance leads to inefficiency and patient morbidity., Aims and Methods: A phone survey of urology out-patient non-attenders over 1-month was performed to determine reasons for non-attendance, to identify patients who could be discharged, and the manner in which patients want reminders., Results: Seventy-six non-attenders were contacted. Fourteen were GP referred new patients. The reason for non-attendance (n = 10) was due to patient issues. Of the patients due for review (n = 62), it was a first non-attendance in 56. Only 41 (66%) claimed to have received notification or appointment cards. Eight patients said they were written to and 13 (21%) denied either receiving a written notification or an appointment card. Only eight patients rang to confirm/change their appointment. Ninety-nine percent said that they would like a further appointment by text message (34%), phone (37%), letter (36%) or email (6%)., Conclusions: We now hope to implement a number of methods to further reduce non-attendance rates based on the findings in this study.

Background: PSA measurement is important in prostate cancer detection. However, applying cut-off values of >4 ng/ml as indication for biopsy misses 20-30% of tumours., Aims: To determine the number of patients with prostate cancer and normal age-related PSA, referred for TRUS biopsy due to abnormal DRE alone., Methods: We reviewed patients referred for biopsy over 12 months. Indication for biopsy included abnormal PSA, abnormal DRE, or both., Results: Four-hundred and sixty-five (465) TRUS biopsies were performed, 209 were positive. Of the 183 (183/209) positive on whom complete data were available, 4 (2.2%) had a normal age-related PSA but an abnormal DRE., Conclusions: Metastatic prostate cancer remains incurable. Therefore detection of organ-confined and potentially curable disease, is crucial. Though PSA has led to earlier detection, this study emphasises the importance of clinical examination, illustrating a normal PSA cannot eliminate the possibility of cancer. DRE and PSA should be interpreted as being collaborative, not competitive.

"How Does Service Drive the Service Company?" presents commentators on Leonard A. Schlesinger and James L. Heskett's September-October article. Commentators include Michael R. Quinlan, Ron Zemke, Jim Snider, Dinah Nemeroff, Steven S. Reinemund, Robert Ayling, Karmjit Singh, James A. Perkins, Joseph E. Antonini, and Walter F. Loeb.