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This qualitative study evaluates physician training and experience with treatment and prevention services for people who inject drugs (PWID) including medications for opioid use disorder (MOUD) and HIV pre-exposure prophylaxis (PrEP). The Behavioral Model of Healthcare Utilization for Vulnerable Populations was applied as a framework for data analysis and interpretation. Two focus groups were conducted, one with early career physicians (n = 6) and one with mid- to late career physicians (n = 3). Focus group transcripts were coded and analyzed using thematic analysis to identify factors affecting implementation of treatment and prevention services for PWID. Respondents identified that increasing the availability of providers prescribing MOUD was a critical enabling factor for PWID seeking and receiving care. Integrated, interdisciplinary services were identified as an additional resource although these remain fragmented in the current healthcare system. Barriers to care included provider awareness, stigma associated with substance use, and access limitations. Providers identified the interwoven risk factors associated with injection drug use that must be addressed, including the risk of HIV acquisition, notably more at the forefront in the minds of early career physicians. Additional research is needed addressing the medical education curriculum, health system, and healthcare policy to address the addiction and HIV crises in the U.S. South.

Introduction: Ending the HIV Epidemic initiatives provide a unique opportunity to use implementation scientific methods to guide implementation of evidence-based practices and evaluate their effectiveness in real-word settings to improve HIV inequities. This report demonstrates our use of Implementation Mapping (IM) to engage participating county health departments, AIDS services organizations, and community-based organizations in the development of a data dashboard to track the PrEP care continuum for the state of Alabama, an Ending the HIV Epidemic hotspot., Methods: Our project is guided by an overarching Implementation Research Logic Model and by the tenets of IM, a 5-step approach to support researchers and community partners in the systematic selection, development, and/or tailoring of implementation strategies to increase program adoption, implementation, and sustainability., Results: Step 1, the needs assessment, established baseline data elements for a PrEP care continuum for participating community-based organizations, AIDS services organizations, and the state health department as well as investigated their desire for data visualization and willingness to share data to inform initiatives to improve PrEP access. Step 2 identified adaptability, relative advantage, and complexity as determinants of intervention adoption. Based on findings from steps 1 and 2, the investigators and community partners determined to move forward with development of a data dashboard. Step 3 identified the following implementation strategies to support a dashboard, including development of educational materials, synchronous and asynchronous training, technical assistance, and improved record systems., Discussion: Using IM supports community-engaged researchers in designing strategies to end the epidemic that are context-specific and more impactful in real-word settings., Competing Interests: L.E. is currently receiving a grant (MK8591-022) from Merck, has consulted for Black AIDS Institute, and is a speaker for MedIQ who provide CME. The remaining authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Context: The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology., Objective: We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience., Evidence Acquisition: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system., Evidence Summary: The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report., Conclusions: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion., (Copyright © 2012 AEU. Published by Elsevier Espana. All rights reserved.)

Context: The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology., Objective: We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination., Evidence Acquisition: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system., Evidence Summary: The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice., Conclusions: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion., (Copyright © 2012 AEU. Published by Elsevier España, S.L. All rights reserved.)

Context: A summary of the 2nd International Consultation on Bladder Cancer recommendations on the reconstructive options after radical cystectomy (RC), their outcomes, and their complications., Objective: To review the literature regarding indications, surgical details, postoperative care, complications, functional outcomes, as well as quality-of-life measures of patients with different forms of urinary diversion (UD)., Evidence Acquisition: An English-language literature review of data published between 1970 and 2012 on patients with UD following RC for bladder cancer was undertaken. No randomized controlled studies comparing conduit diversion with neobladder or continent cutaneous diversion have been performed. Consequently, almost all studies used in this report are of level 3 evidence. Therefore, the recommendations given here are grade C only, meaning expert opinion delivered without a formal analysis., Evidence Synthesis: Indications and patient selection criteria have significantly changed over the past 2 decades. Renal function impairment is primarily caused by obstruction. Complications such as stone formation, urine outflow, and obstruction at any level must be recognized early and treated. In patients with orthotopic bladder substitution, daytime and nocturnal continence is achieved in 85-90% and 60-80%, respectively. Continence is inferior in elderly patients with orthotopic reconstruction. Urinary retention remains significant in female patients, ranging from 7% to 50%., Conclusions: RC and subsequent UD have been assessed as the most difficult surgical procedure in urology. Significant disparity on how the surgical complications were reported makes it impossible to compare postoperative morbidity results. Complications rates overall following RC and UD are significant, and when strict reporting criteria are incorporated, they are much higher than previously published. Fortunately, most complications are minor (Clavien grade 1 or 2). Complications can occur up to 20 yr after surgery, emphasizing the need for lifelong monitoring. Evidence suggests an association between surgical volume and outcome in RC; the challenge of optimum care for elderly patients with comorbidities is best mastered at high-volume hospitals by high-volume surgeons. Preoperative patient information, patient selection, surgical techniques, and careful postoperative follow-up are the cornerstones to achieve good long-term results., (Copyright © 2012 European Association of Urology. All rights reserved.)

Context: The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology., Objective: We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience., Evidence Acquisition: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system., Evidence Summary: The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report., Conclusions: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology., Objective: We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination., Evidence Acquisition: Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system., Evidence Summary: The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice., Conclusions: These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: Closure of the perineum following radical excision of pelvic tumours can prove to be a complex surgical problem. A number of pedicled flaps have been used for perineal reconstruction in order to reduce post-operative complications such as infection and abscess formation. The aim of this case series was to analyse the use of pre-operative computer tomography (CT) angiography to guide flap selection for perineal reconstruction following radical excision of pelvic tumours., Methods: We conducted a retrospective review to identify all patients who underwent CT angiography prior to radical excision of pelvic tumours and planned flap reconstruction over an 18 month period. Six patients were identified and are presented in this case series. Patients' medical records, histology reports, pre-operative investigations and CT angiograms, complications and follow-up were reviewed., Results: The mean patient age was 58.3 years, with a male to female ratio of 1:2. Four out of six patients (66.6%) underwent pre-operative radiotherapy. The deep inferior epigastric arteries (DIEA) were visualised in all six cases (100%) and the pre-operative CT angiography helped guide flap choice in all cases (100%). In one case, narrowing of the DIEA vessels was noted precluding the use of a DIEA-based flap. One patient had a minor superficial wound dehiscence., Conclusion: Pre-operative CT angiography allows accurate visualisation of the DIEA system including perforator vessels. CT angiography is a useful tool, providing the surgical team with significant additional information to aid pre-operative planning and optimise reconstructive choice and outcome., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Removal of bowel segments for the purposes of urinary diversion may have a significant effect on bowel function. The remaining bowel may not be able to fulfill its normal role, resulting in not only malabsorption syndromes, but also dysfunctional defecation. Provided, however, care is taken in selecting patients and the bowel segments for such procedures and follow-up is vigilant, complications should be minimal. There appears to be a significant risk of developing symptoms of increased bowel frequency following urinary diversion and reconstruction. Patients need to be counselled regarding this prior to surgery, however, further data needs to be collected to accurately quantify the risk and the effect it has on quality of life.

Objective: To investigate whether the expression of P2X(3) receptors (implicated in the pathophysiology of pain) is altered in human bladder urothelium from patients with interstitial cystitis (IC, a major symptom of which is pain), and as P2X(2) receptors can be co-expressed with P2X(3) receptors, to assess their expression also., Patients and Methods: Bladder tissue samples were collected from patients undergoing cystectomy or radical prostatectomy. Patients with IC were diagnosed using the international criteria. RNA protein expression levels of both receptors were evaluated using reverse transcription-polymerase chain reaction (PCR), real-time quantitative PCR and Western blot analysis., Results: P2X(2) was expressed in the human urothelium, in a glycosylated form. There was less gene expression of P2X(3) in IC urothelium, whereas P2X(2) gene expression was unchanged. This contrasted with the protein expression, which was increased for both P2X(2) and P2X(3)., Conclusion: This is the first report of the expression of the P2X(2) receptor in human bladder urothelium. There was greater protein expression of both P2X(2) and P2X(3) in IC bladder urothelium which did not directly correlate with the gene expression. Changes in expression of P2X(2) and P2X(3) receptors may contribute to the pain that patients with IC have, and might provide novel drug targets.

Objective: To determine the validity of a system for coding the reason for urological referral from primary care, using ICD10, and thus enable benchmarking of urological outpatient activity., Patients and Methods: Four studies were conducted: (i) A pilot study to aggregate information into a few input diagnosis codes (925 patients); (ii) Validation of the aggregated codes using input diagnoses from a second centre (928 patients); (iii) A prospective study by three urologists to determine the system's generic utility (918 patients); (iv) A study to aggregate the presumptive codes for 2771 patients to gain an insight into the case-mix of patients referred to a general urological service via the outpatient department., Results: The aggregation of input diagnoses from general practice referrals into 36 'presumptive codes' was possible and could be validated. Prospective coding, for 96% of eligible patients, was possible with < 1% of referral diagnoses not being codable. Further aggregation of the data for 2771 patients showed that 31% were referred with urological malignancy whilst 69% had symptoms suggesting benign urological disease., Conclusions: This preliminary study of presumptive coding suggests that it is a feasible and valid method of recording the input diagnoses for patients presented to a urological service. The information it provides has relevance for the structuring, benchmarking, resourcing and manpower requirements of that service, essential components for clinical governance. It also has relevance to the prospective collection of patient data for research and audit.

Background: Because cystoscopy is invasive and expensive and urine cytology has low sensitivity, alternative methods for detecting bladder cancer are sought. Minichromosome maintenance (Mcm) proteins have been used as diagnostic markers for cervical cancer. We investigated whether one Mcm protein, Mcm5, can be used to detect urothelial cancer cells in urine sediments., Methods: We used two monoclonal antibodies against His-tagged human Mcm5 (amino acids 367-582) in an immunofluorometric assay to measure Mcm5 levels in cells in the urine of 353 patients who presented with hematuria or lower urinary tract symptoms or who were undergoing follow-up cystoscopy for urothelial neoplasia. Urine samples were also subjected to routine cytologic analysis. Patients underwent upper urinary tract imaging and cystoscopy within 12 hours of producing the urine sample. Data were analyzed by comparing areas under a nonparametric receiver operating characteristics (ROC) curve and by McNemar's test and Fisher's exact test. All statistical tests were two-sided., Results: At the assay cut point where the false-negative and false-positive rates were the same, the Mcm5 test detected primary and recurrent bladder cancers with 87% (95% confidence interval [CI] = 77% to 94%) sensitivity and 87% (95% CI = 83% to 91%) specificity. At the cut point where the specificities of urine cytology and the Mcm5 test were equal (97%, 95% CI = 95% to 99%), the Mcm5 test was statistically significantly (P<.001) more sensitive than urine cytology, 73% (95% CI = 61% to 83%) versus 48% (95% CI = 35% to 60%). At the lower detection limit of the Mcm5 test, sensitivity was highest, 92% (95% CI = 83% to 97%) and specificity was 78% (95% CI = 72% to 83%). Patients with prostate cancer had higher levels of Mcm5 in their urine sediments than did men without malignancy (P<.001)., Conclusions: Elevated levels of Mcm5 in urine sediments are highly predictive of bladder cancer.

Purpose: We evaluate the outcome in patients with node positive bladder cancer with particular reference to the effect of individual characteristics of positive nodes on survival after meticulous pelvic lymphadenectomy at cystectomy., Materials and Methods: This prospective analysis contains 452 cases of bladder cancer staged preoperatively as N0M0, managed with pelvic lymphadenectomy and cystectomy between 1984 and 1997. A total of 83 (18%) patients with histologically confirmed node positive disease are included in our study., Results: The median overall survival of patients with positive nodes was 20 months. Median 5-year survival was 29%. Patients who survived were found with positive nodes at each site in the pelvis. The median survival of 57 patients with less than 5 positive nodes was 27 months, compared with 15 months for 26 with 5 nodes or more (log-rank test p = 0.0027). Median survival of 26 patients with no lymph node capsule perforation was 93 months, compared with 16 months for 57 with capsule perforation (p = 0.0004). The median survival of 18 patients with a maximum diameter of lymph node metastasis up to 0.5 cm. was 64 months, compared with 16 months for 65 with nodal metastasis greater than 0.5 cm. (p = 0.024). Contralateral positive nodes were found in 16 of 39 (41%) patients with unilateral bladder cancer., Conclusions: Long-term survival is possible with node positive bladder cancer. Those patients with few as well as smaller and, therefore, unsuspected nodal metastases, and those without lymph node capsule perforation have the best results after removal of pelvic metastatic nodal disease. Because patients who survive may be found regardless of the site of pelvic nodal metastases, meticulous bilateral pelvic lymphadenectomy is warranted in all patients at the time of attempted curative cystectomy for bladder cancer, particularly if there is no clinical evidence of nodal involvement.

Purpose: Continence after orthotopic bladder substitution may be influenced by characteristics of the reservoir and of the sphincter mechanism. Autonomic innervation probably contributes to pressure generation by the sphincter mechanism at rest. We therefore examined the effect of nerve sparing cystectomy technique on continence in 165 consecutive men who underwent cystectomy and construction of an ileal low pressure reservoir and were followed regarding continence for at least 3 months postoperatively., Materials and Methods: Nerve sparing was attempted bilaterally in 20 men, unilaterally in 96 and not at all in 49. Patients were followed prospectively and completed regular voiding diaries, including details of continence. Postoperative sexual potency was ascertained by questionnaire. The effects of attempted nerve sparing and of age on continence were examined in Kaplan-Meier models and in Cox's proportional hazards models., Results: Median times to continence during the day and at night for all men were 3 and 9 months, respectively. Continence differed significantly between patients with attempted nerve sparing and no attempt at nerve sparing (day, p = 0.003 and night, p = 0.001, log rank test) and between men less than 65 years old and those older than 65 (day, p = 0.037 and night, p = 0.005, log rank test). In the multivariate analysis, attempted nerve sparing was significantly associated with improved continence by day (t = 1.96) and by night (t = 1.98)., Conclusions: These data suggest that attempted nerve sparing is associated with improved urinary continence after orthotopic bladder substitution.

New insights into bladder cancer mechanisms have not yet produced clinical benefit. Without novel treatments, cystectomy remains the most effective local treatment, albeit the most aggressive. Uncertainty about the natural history of bladder cancer, the progression rate after other treatments, the risks of cystectomy and subsequent quality of life, foster debate about the indications for cystectomy. There are numerous urinary diversions and bladder substitutes. Differences in tumour extent, patient age, performance status, renal and mental function, and acceptance make different diversion techniques necessary. Urologists need not know every technique, but should know at least one technique of each class: an incontinent diversion (such as the ileal conduit), ureterosigmoidostomy, continent reservoir, and orthotopic bladder substitute. The common principles, advantages, and contraindications of these techniques are discussed.

The smooth muscle of the normal bladder wall must have some specific properties. It must be very compliant and able to reorganise itself during filling and emptying to accommodate the change in volume without generating any intravesical pressure, but whilst maintaining the normal shape of the bladder. It must be capable of synchronous activation to generate intravesical pressure at any length to allow voiding. The cells achieve this through spontaneous electrical activity combined with poor electrical coupling between cells, and a dense excitatory innervation. In the diseased state, alterations of the smooth muscle may lead to failure to store or failure to empty properly. The diseased states discussed are bladder instability and diabetic neuropathy. Bladder instability is characterised urodynamically by uninhibitable rises in pressure during filling, and is seen idiopathically and in association with bladder outflow obstruction and neuropathy. In diabetic neuropathy, many of the smooth muscle changes are a consequence of diuresis, but there is evidence for alterations in the sensory arm of the micturition reflex. In the unstable bladder, additional alterations of the smooth muscle are seen, which are probably caused by the patchy denervation that occurs. The causes of this denervation are not fully established. Nonsurgical treatment of instability is not yet satisfactory; neuromodulation has some promise, but is expensive, and the mechanisms poorly understood. Pharmacological treatment is largely through muscarinic receptor blockade. Drugs to reduce the excitability of the smooth muscle are being sought, since they may represent a better pharmacological option.

Purpose: Intestinal low pressure orthotopic bladder substitutes have no major coordinated contractions during micturition. Therefore, the importance and type of reflux prevention were assessed in a prospective randomized study., Materials and Methods: A total of 70 patients with an ileal low pressure bladder substitute was randomized to receive a nipple valve or an isoperistaltic afferent ileal tubular segment for reflux prevention., Results: After median observation times of 57 and 45 months, respectively, the results regarding functional reservoir capacity, incidence of infected urine, urinary continence, voiding habits and serum electrolytes, urea and creatinine were similar in both groups. Severe upper tract dilatation due to ureteroileal or nipple stenosis occurred in 9 of 67 evaluable reno-ureteral units (13.5%) in patients with antireflux nipples and in 2 of 69 (3%) in patients with an afferent tubular segment. This difference in favor of the latter cases is significant (Fisher's exact test p < 0.03). Video urodynamics did not show reflux of contrast medium during voiding in either group. A simultaneous intravesical, intra-abdominal and intrapelvic pressure increase was noted during the Valsalva maneuver., Conclusions: While long-term upper tract preservation by an afferent tubular ileal segment must be confirmed in larger patient series with longer followup, our results indicate that reflux prevention in patients with orthotopic low pressure bladder substitutes is not a major concern and does not justify the use of antireflux mechanisms with a high complication rate.

We report on 10 years of experience with an ileal low-pressure bladder substitute combined with an afferent tubular segment following cystectomy in 100 consecutive men. The median follow-up period was 30 months (range 3-108 months), with a 2.5-year minimum in survivors. A total of 42 patients died, 33 of these dying of bladder cancer. The early complication rate was 11%, including 2 deaths due to postoperative sepsis. In all, 14 patients required reoperation for late complications. The reservoir's median functional capacity increased to 500 ml at 12 months and was paralleled by improving continence: 92% by day (after 1 year) and 80% by night (after 2 years). Four ureteric strictures occurred. No coordinated, isolated pressure rise developed in the reservoir during voiding, which was accomplished by pelvic floor relaxation with abdominal straining, if necessary. Raised intraabdominal pressure acted equally on the reservoir and ureters, preventing reflux during voiding. This technique is straightforward, allows radical cancer surgery, and protects the upper tract. The favorable functional results are comparable with those achieved by similar techniques, but meticulous follow-up is essential.

Thoracic bio-impedance cardiography was used to study the haemodynamic changes in 28 patients undergoing transurethral prostatectomy (TURP) under either general or spinal anaesthesia. Cardiac output and mean arterial pressure fell with induction of general anaesthesia, whilst mean arterial pressure and systemic vascular resistance fell with induction of spinal anaesthesia. The transthoracic fluid index fell during resection under general anaesthesia, but no significant haemodynamic changes were seen during resection under either anaesthetic. This study suggests that resection has no specific adverse haemodynamic consequences. Spinal anaesthesia may produce less haemodynamic disturbance than general anaesthesia in patients undergoing TURP and formal comparison of the 2 techniques seems necessary.

Bladder outflow tract obstruction was produced in immature female guinea-pigs. Obstruction caused an increase in voiding pressure and bladder weight and a decrease in bladder compliance. No change occurred in the sensitivity of obstructed detrusor strips to exogenous agonists, but the force of contraction and response to electrical stimulation of the intrinsic nerves were less than in the strips from controls. The response of strips from sham-operated animals to exogenous agonists and to electrical stimulation was greater than that from obstructed animals. The effects of length and tension could not account for the in vitro responses from obstructed animals. Histology after obstruction showed muscle hypertrophy, connective tissue infiltration and decrease in nerve density. Many of the changes resembled those seen in the obstructed human bladder.

A combination of transrectal and transabdominal ultrasound was compared with flexible cystoscopy as a means of detecting recurrent bladder tumours. The study group comprised 50 patients who had previously had rigid cystoscopy. They underwent combination ultrasound in the out-patient department 1 week before flexible cystoscopy. Combination ultrasound identified 25 patients with recurrent tumours and flexible cystoscopy identified 26. Thirty-four patients (68%) preferred ultrasound, 10 (20%) preferred flexible cystoscopy, 3 (6%) preferred general anaesthesia and rigid cystoscopy and 3 (6%) had no preference. The main objection to ultrasound was the use of the transrectal probe.

Ureteric injury is a recognized complication of hysterectomy and may present with obstruction or fistula. Between 1987 and 1989 in Oxford nine patients with 10 injured ureters underwent attempted retrograde placement of double J stents. Three patients had successful outcomes and one patient with bilateral ureteric obstruction required reimplantation of the right ureter after successful stenting of the left ureter. One patient required removal of a stent due to irritation but her fistula eventually closed. In three patients placement was unsuccessful and in one patient injury to the bladder base prevented the ureteric orifices from being seen and hence stenting was not possible. Thus five of these 10 injured ureters were managed successfully with double J stents. We advocate the initial use of double J stents in gynaecological ureteric injury. This approach is simple and may cure the fistula. If it is unsuccessful, subsequent reimplantation is not hindered.

Transrectal and transabdominal ultrasound combined with cytology were compared with conventional cystoscopy as a mean of detecting recurrences of bladder tumours. One hundred and twenty-five patients underwent combination ultrasound in the outpatient department 1 week before cystoscopy. Combination ultrasound identified 90% of recurrent tumours and tumour identification with the results of ultrasound and cytology combined was 93%. The false positive rate was 2%. The ultrasonographer would have referred 97% of patients with recurrent tumour for cystoscopy. Combination ultrasound and cytology may be a satisfactory alternative to check cystoscopy in certain categories of bladder tumours.

Culture supernatants of 26 strains of Staphylococcus aureus possessing delta-hemolytic activity have been tested by immunodiffusion against a serum raised against purified delta-hemolysin from S. aureus CN 4108 (Newman D2). Supernatants from 14 strains of canine origin gave a reaction of partial identity with delta-hemolysin from CN 4108, whereas supernatants from all other strains had full identity. Delta hemolysin from one of these canine strains, CN 7450, was purified by ammonium sulfate fractionation and precipitation at pH 4.5. The physical, chemical, and biological properties of this toxin were compared with those of delta-hemolysin from CN 4108. Differences in molecular weight (as judged by Sepharose 6B chromatography), isoelectric point, and amino acid composition were found. Both toxins caused dermonecrosis in rabbits, lysed erythrocytes from several different species, and were inhibited by normal sera and phospholipids. Unlike delta-hemolysin from CN 4108, the hemolytic activity of delta-hemolysin from CN 7450 was found to be dependent on the incubation temperature over the range of 25 to 37 degrees C. Immunodiffusion results obtained with antisera raised against purified delta-hemolysin from CN 7450 indicated that delta-hemolysins from the canine strains were probably identical and confirmed that these differ immunologically from delta-hemolysin from CN 4108.

Although there have been many reports on injuries to occupants of cars in road traffic accidents, there have been few prospective studies of injuries to pedestrians in such accidents. For this reason a two year prospective study of pedestrians in road traffic accidents in the Oxford region was carried out. The incidence of death in pedestrians was significantly higher than in car occupants or motorcyclists. The principal determinant of death was the weight of the vehicle concerned. The most common site of injury was the head because of a high incidence of brief concussion, but the most common site of serious injuries was the leg. Injuries to all regions of the body increased with age and with the weight of the vehicle in the collision. Accidents most often concerned young children or the elderly.

Intravenous digital subtraction angiography is relatively hazardous and inaccurate. It appears from the literature to have little place in either the screening of patients with putative carotid artery disease or in the assessment of those about to undergo carotid endarterectomy.

Sera of rabbits immunized with pili or formalized cultures of Neisseria gonorrhoeae contained pili antibodies. The reaction between pili and specific gamma globulin was followed by direct visual observation with an electron microscope. Using pili from 31 strains and antisera against three strains, only a few crossreactions between pili were observed. From this it is concluded that gonococcal pili are antigenically heterogeneous. However, serum raised with a T3 culture (with no detectable pili) contained antibodies against pili of the homologous T2 strain. It is proposed that the pilus antigen may exist in a form different from the typical pilus in gonococci.

A new haemolysin from Staphylococcus aureus produced opaque zones of haemolysis on horse blood agar but did not lyse equine erythrocytes suspended in phosphate-buffered saline. The haemolysin was not neutralized by normal rabbit serum and was distinct from alpha-, beta- and delta-haemolysins as well as human leucocidin. Partially purified preparations produced erythema when injected intradermally into rabbit skin.

Ninety-three patients who underwent surgery were studied retrospectively over a five-year period for complications of diverticular disease, including free perforation in 32 patients (with fecal peritonitis in 8), inflammation or peritonitis in 22 patients, an abscess in 11 patients, and intestinal obstruction in 14 patients. Sixty-eight patients (73 percent) had systemic symptoms and signs consistent with serious sepsis. There has been a growing popularity of the Hartmann procedure throughout the study period. The overall 30-day mortality rate was 10.8 percent. Because of a high proportion of poor-risk patients, the Hartmann group fared particularly badly compared with those who had other operations, with a 28 percent mortality rate, 69 percent incidence of major complications, and one third of the survivors having a permanent colostomy. Other operative procedures are discussed, but until prospective data become available, it is unlikely that the widespread popularity of the Hartmann procedure will decline. Therefore, the importance of meticulous attention to technical detail is stressed if results are to improve.

Antibodies against delta-haemolysin from Staphylococcus strain CN4108 (Newman) did not neutralise delta-haemolysin from the canine strain of S. aureus CN7450 to the same extent as delta-haemolysin prepared from S. aureus strain CN4108. This is additional evidence for the immunological distinctness of delta-haemolysin from these two S. aureus strains of human and canine origin.