The role of robotic surgery in the treatment of urolithiasis.

Renal stones in the modern era are most commonly treated with minimally invasive techniques and using endourological procedures. However, for more complex cases, there is renewed interest in exploring laparoscopic or robotic techniques that can offer patients significant benefits over otherwise multiple endourologic or open surgical intervention. In clinical circumstances with anomalous anatomy, indication for concomitant reconstruction, or previously failed endourological intervention, robotic and laparoscopic approaches may offer suitable, if not more effective, treatment options.

Nutritive value, fermentation characteristics, and in situ disappearance kinetics of ensiled warm-season legumes and bahiagrass.

This study determined the nutritive value, ensiling characteristics, and in situ disappearance kinetics of bahiagrass (Paspalum notatum Flügge 'Tifton 9'), perennial peanut (Arachis glabrata Benth. 'Florigraze'), annual peanut [Arachis hypogaea (L.) 'FL MDR 98'], cowpea [Vigna unguiculata (L.) Walp. 'Iron clay'], and pigeonpea [Cajanus cajan (L.) Millsp. 'GA-2']. All forages were harvested at maturity stages that optimized dry matter (DM) yield and nutritive value. After harvest, forages were wilted to 45% DM, and 4 replicate bales of each legume and 8 bales of bahiagrass were wrapped in polyethylene and ensiled for 180 d. After each bale was opened, the forage was thoroughly mixed, and representative subsamples were taken for laboratory analysis and in situ incubation. Wilting and ensiling decreased the rumen-undegradable protein, water-soluble carbohydrate, crude protein (CP), and in vitro true digestibility (IVTD) of bahiagrass, perennial peanut, and cowpea, and increased their neutral detergent fiber (NDF) concentrations. Among haylages, CP concentration was greatest for annual peanut, followed by perennial peanut and cowpea, and least for bahiagrass. In contrast, NDF concentration was greater in bahiagrass than in legumes. Pigeonpea had the greatest NDF concentration among legumes and lowest IVTD of all haylages. All haylages were aerobically stable for at least 84 h, but pH was lower in perennial peanut and cowpea than in pigeonpea. Ammonia-N concentrations tended to be greater in legume haylages than in bahiagrass haylage. Butyrate concentration was greater in annual and perennial peanut than in bahiagrass. Total VFA concentration was greater in annual and perennial peanut and cowpea haylages than in bahiagrass haylage. Undegradable DM fractions were greater and extent of DM degradation was lower in bahiagrass and pigeonpea than in other haylages but lag time and degradation rates did not differ. Annual and perennial peanut and cowpea haylages were as aerobically stable and had greater CP, IVTD, and extent of degradation than did bahiagrass haylage; therefore, they are promising forages for dairy cow diets in the southeastern United States.

Distribution of D1 and D5 dopamine receptors in the primate nucleus accumbens.

The D1 family of dopamine receptors (D1R) play a critical role in modulating reward in the nucleus accumbens (NAc). A better understanding of how D1Rs modulate NAc function must take into account the contributions of the two D1R subtypes, D(1) and D(5). In order to determine how these two subtypes contribute to dopamine's actions in the NAc, we utilized subtype specific antibodies and immunoelectron microscopy to quantitatively determine the localization of D(1) and D(5) in the neuropil of the primate NAc. We found that D(1) was more commonly found in dendritic shafts and spines, while D(5) was more commonly found in axon terminals, preterminal axons and glial processes. However, D(5) is well positioned to play an important role in postsynaptic modulation of inputs onto NAc medium spiny neurons. Approximately one third of spines contained D(1) and one quarter contained D(5), and as we have previously observed in the prefrontal cortex (PFC) and amygdala, these receptors overlapped extensively in dendritic spines. Similarly, we found overlap of the two D1R in axon terminals in the NAc; however, here D(5) labeled the larger population of terminals and D(1) was found in a subpopulation of D(5) containing terminals. Given the higher affinity of D(5) for dopamine, this suggest that presynaptic modulation of inputs by dopamine may be more easily evoked than in PFC where D(1) is the dominate presynaptic receptor. Finally, we investigated differences between the NAc and the dorsal striatum. We found that in the caudate half of dendritic spines contain D(1), significantly more than in the NAc. This suggests differences in how receptor is translated and distributed in D(1) mRNA expressing medium spiny neurons in the NAc and caudate.

Localization of dopamine- and cAMP-regulated phosphoprotein-32 and inhibitor-1 in area 9 of Macaca mulatta prefrontal cortex.

The actions of dopamine D1 family receptors (D1R) depend upon a signal transduction cascade that modulates the phosphorylation state of important effector proteins, such as glutamate receptors and ion channels. This is accomplished both through activation of protein kinase A (PKA) and the inhibition of protein phosphatase-1 (PP1). Inhibition of PP1 occurs through PKA-mediated phosphorylation of dopamine- and cAMP-regulated phosphoprotein 32 kDa (DARPP-32) or the related protein inhibitor-1 (I-1), and the availability of DARPP-32 is essential to the functional outcome of D1R activation in the basal ganglia. While D1R activation is critical for prefrontal cortex (PFC) function, especially working memory, the functional role played by DARPP-32 or I-1 is less clear. In order to examine this more thoroughly, we have utilized immunoelectron microscopy to quantitatively determine the localization of DARPP-32 and I-1 in the neuropil of the rhesus monkey PFC. Both were distributed widely in the different components of the neuropil, but were enriched in dendritic shafts. I-1 label was more frequently identified in axon terminals than was DARPP-32, and DARPP-32 label was more frequently identified in glia than was I-1. We also quantified the extent to which these proteins were found in dendritic spines. DARPP-32 and I-1 were present in small subpopulations of dendritic spines, (4.4% and 7.7% and respectively), which were substantially smaller than observed for D1R in our previous studies (20%). Double-label experiments did not find evidence for colocalization of D1R and DARPP-32 or I-1 in spines or terminals. Thus, at the least, not all prefrontal spines which contain D1R also contain I-1 or DARPP-32, suggesting important differences in D1R signaling in the PFC compared to the striatum.

A long-term prospective analysis of pediatric unilateral inguinal hernias: should laparoscopy or anything else influence the management of the contralateral side?

PURPOSE: To prospectively determine if children who present with a unilateral inguinal hernia can be identified as at risk for developing a metachronous inguinal hernia (MIH) based on risk factors and laparoscopic findings of the contralateral internal ring. MATERIALS AND METHODS: Between April 2000 and October 2004, 299 patients with a unilateral inguinal hernia were followed prospectively. Laparoscopy was attempted in each child. Bilateral repair was only performed in those with contralateral swelling or crepitus during laparoscopic evaluation. All other children were followed regardless of laparoscopic findings. Risk factors to include premature delivery, family history and increased abdominal pressure were recorded. Clinical follow up and annual phone interviews were performed to determine the development of a MIH. RESULTS: Thirteen patients underwent initial bilateral inguinal hernia repair. Of the remaining 286 patients (272 boys, 14 girls; ages 54+/-50.8 months), laparoscopy revealed 127 closed, 48 cleft and 67 open (contralateral patent processus vaginalis) contralateral internal rings, and in 44 laparoscopy was not possible due to a small hernia. Of 222 patients followed for 53.2 months (30.1-82.5 months), 15 (6.8%) developed a MIH. When comparing age, gender, laterality, laparoscopic findings, family history, premature birth and intra-abdominal pressure, only family history exhibited a significant risk for MIH (33% vs 7.7%). However, 16/21 children with a family history never developed a MIH, and 47/53 children with a contralateral patent processus vaginalis have yet to develop one. CONCLUSIONS: Risk factors and laparoscopic findings failed to predict the few children who would develop a MIH. The contralateral side should not be routinely explored by any methodology.

Diagnosis of ureteral obstruction during complex urogynecologic surgery.

Intraoperative cystoscopy has been recommended to identify unsuspected bladder and ureteral injuries resulting from gynecologic surgery. We retrospectively reviewed 157 cases of complex urogynecologic procedures at our institution. Intraoperative cystoscopy revealed no bladder injuries. Five cases of unsuspected ureteral obstruction were identified (3.2%). One case of ureteral ligation was diagnosed and repaired intraoperatively. The remaining 4 cases were found to represent chronic ureteral obstruction resulting from pelvic organ prolapse (2 cases), ureteropelvic junction obstruction (1 case) and stenosis of the ureterovesical junction after transurethral resection (1 case). Intraoperative assessment required an average of 90 minutes. Our experience suggests that pre-existing ureteral obstruction may be more common than intraoperative injury. In selected populations, routine preoperative assessment of the ureters is indicated to simplify intraoperative evaluation.

A comparison of anti-biotin and biotinylated anti-avidin double-bridge and biotinylated tyramide immunohistochemical amplification.

Often it is difficult to detect very small amounts of antigen with conventional immunohistochemical techniques. We evaluate three amplification techniques involving anti-biotin or anti-avidin double-bridges or biotinylated tyramide amplification to enhance the sensitivity of serotonin transporter immunohistochemistry. For the anti-biotin double-bridge, after the secondary antibody, the sections were incubated in anti-biotin antibody followed by a second incubation in the secondary antibody and then avidin-biotin-peroxidase complex (ABC). For the biotinylated anti-avidin technique, after the ABC, sections were incubated in biotinylated anti-avidin, followed by another incubation in ABC. For the biotinylated tyramide technique, after the ABC step, sections were incubated in biotinylated tyramide and hydrogen peroxide, followed by another incubation in ABC. The anti-biotin double-bridge also resulted in a large increase in the number of stained fibers and the intensity of labeling with no increase in background. A biotinylated anti-avidin double-bridge also produced significant signal amplification but significant background. The biotinylated tyramide technique resulted in an even larger increase in the number of labeled fibers and an intensity of their staining with a moderate amount of background staining. However, this advantage was not present at high dilutions of primary antibody. Thus, the anti-biotin double-bridge is likely to be useful in immunohistochemistry and immunofluorescence as well as other situations where increased sensitivity and low background from biotin markers is needed. The biotinylated tyramide technique may also be useful where some degree of background labeling is acceptable.

Familial gonadotropin-releasing hormone resistance and hypogonadotropic hypogonadism in a family with multiple affected individuals.

OBJECTIVE: To characterize the phenotype of idiopathic hypogonadotropic hypogonadism due to compound heterozygous GnRHR gene mutations (Arg262Gln/Tyr284Cys). DESIGN: Retrospective review. SETTING: Tertiary medical center. PATIENT(S): Family containing four siblings (three female and one male) with complete idiopathic hypogonadotropic hypogonadism. INTERVENTION(S): Baseline and stimulated laboratory studies. One patient received GnRH treatment and one received human menopausal gonadotropins. MAIN OUTCOME MEASURE(S): Clinical phenotype vs. genotype is assessed by endocrine studies, karyotype, pedigree, and review of pathology slides of ovarian neoplasm. RESULT(S): With GnRH stimulation, two patients with idiopathic hypogonadotropic hypogonadism had maximum LH < 10 mIU/mL, and two others had peak LH > 10 mIU/mL. With repeated GnRH stimulation 24 hours later, gonadotropin levels in all patients were increased. Stimulation of thyroid-releasing hormone and tests for insulin-induced hypoglycemia were normal. One affected patient did not ovulate after GnRH treatment, but her sister ovulated with gonadotropin treatment. Another affected sibling had bilateral oophorectomy for seromucinous cystadenomas, and her hypogonadotropic state remained after castration. The man with idiopathic hypogonadotropic hypogonadism and his unaffected brother had a ring chromosome 21. CONCLUSION(S): All patients with complete idiopathic hypogonadotropic hypogonadism had the same GnRHR mutations, but clinical presentations and endocrinologic responses were heterogeneous. Gonadotropin levels remained low in patients with idiopathic hypogonadotropic hypogonadism after castration, and ring chromosome 21 was present, suggesting that sequences from this chromosome could affect the idiopathic hypogonadotropic hypogonadism phenotype.

Psychosocial recovery following ICU: experiences and influences upon discharge to the community.

While appropriate referrals to community services upon discharge home may address the physical needs of former intensive care patients, the psychological needs may be overlooked. This pilot study describes the recovery period following discharge to home of former intensive care unit (ICU) patients and their significant others, and identifies factors influencing recovery and the role of community support in the recovery period.Semi-structured interviews were conducted with five patients and four significant others, 6 to 15 weeks following discharge from the ICU. Data were analysed using constant comparison to identify recurring categories and themes. The recovery period was characterized by the patients' focus on physical recovery with the major theme described as 'moving on', incorporating normalizing life, return to usual routines, and leaving behind the ICU experience. Factors influencing the recovery period included individual attitudes, prior experiences, the ICU experience and support of family and friends. Community support was not commonly utilized with participants describing a perceived stigma attached to asking for professional help. Attention to physical needs and care often masked the psychological support received, particularly from family members. Despite awareness of community supports, patients were generally reluctant to avail themselves of any of these services.

Teaching spirituality to nurse practitioner students: the importance of the interconnection of mind, body, and spirit.

PURPOSE: To describe the author's experience in locating and implementing a spiritual assessment tool in teaching a first semester clinical nurse practitioner (NP) course. DATA SOURCES: Selected articles and responses of NP students to the use of the tool. CONCLUSIONS: A spiritual assessment is an important component of a comprehensive health assessment. The use of a formal structured protocol provides a framework for beginning students to become comfortable with sprirituality and spiritual assessments and to begin to recognize spiritual distress in clients. IMPLICATIONS FOR PRACTICE: The protocol used in the course is very extensive and might not be practical in a busy practice setting. An alternative, 4-point assessment is provided.

Progressive dementia: personal and relational impact on caregiving wives.

The purpose of this exploratory study was to examine the perceptions of 115 female spouse caregivers of early to moderate stage dementia patients. Based on patients' cognitive status, cross-sectional comparisons of two groups of caregiving wives were conducted. No group differences were found in measures of caregiver burden, depression, or personal gain. However, wives of patients with greater cognitive impairment experienced lower levels of mastery and more relational deprivation when compared to wives of patients with higher mental status. Supportive approaches might be directed toward helping early dementia caregivers restructure their understanding of, and participation in, their marital relationships in anticipation of changes ahead. Interventions aimed at enhancing a caregiver's sense of personal mastery may help reduce the negative effects of dementia on caregivers' well-being.

Measuring imaging ability in children.

INTRODUCTION: Guided imagery has been suggested as an intervention to help children cope with noxious symptoms associated with medical care. A measure of imaging ability, that is, the ability to generate vivid mental images and to experience those images as if they were real, could be helpful in identifying children most likely to succeed in relieving symptoms with guided imagery. The purpose of this study was to test psychometric properties of a new instrument, the Kids Imaging Ability Questionnaire (KIAQ). METHOD: Three expert clinicians and researchers were asked to review the KIAQ to assess content validity. A convenience sample of 58 children were invited to complete the questionnaire twice to obtain data for tests of reliability and criterion-related validity. RESULTS: Content validity, internal consistency (alpha =.75-.76), and test-retest reliability (r =.73) were acceptable. Criterion-related validity using the Singer Fantasy Proneness Interview as a standard was poor (rho =.31-.46). DISCUSSION: Some psychometric properties were acceptable; however, continued research will be necessary to test validity of the questionnaire and demonstrate a relationship between KIAQ score and success with imagery. With continued research, pediatric nurses may use the KIAQ in practice to identify children most likely to benefit from guided imagery.

Judges' knowledge about sexual offenders, difficulties presiding over sexual offense cases, and opinions on sentencing, treatment, and legislation.

Forty-two Midwestern trial judges responded to a survey designed to assess knowledge about sexual offenders; attitudes toward adjudication, sentencing, treatment, and release; and opinions regarding sexual offender-related legislation. Results indicated that the judges held a variety of beliefs regarding the etiology and dynamics involved in sexual offending which differ from those of most professionals in the field of sexual offender management. However, the judges accurately identified important issues related to victims and some myths about offenders. The importance of retribution and rehabilitation for sexual offenders was emphasized, and considerable support was revealed for controversial legislative issues such as community notification, mandatory registration, and civil commitment of sexual predators. Of particular interest is the finding that, compared to other cases, sexual offense cases were rated by judges as more difficult over which to preside from a legal and technical standpoint, a personal and emotional viewpoint, and a public scrutiny and public pressure perspective. These issues, as well as judges' comments on current systemic and decision-making difficulties, are discussed in terms of the importance of judicial education programs and future research.

Older women and the meaning of health.

Health promotion has become an essential component of comprehensive health care, especially considering the growing female population. Older women, in particular, have demonstrated an increasing need for preventive services or health care maintenance and promotion. These needs consist of services provided by health care professionals that can help women meet their own self-care demands. However, before the health care needs of women can be met, they first must be identified. Using Orem's Self-Care Theory, a three-part qualitative phenomenological study was conducted in an attempt to understand what health actually means to older women and what types of health behaviors they feel are important to maintain or promote health. Three different groups of women age 55 and older with a variety of education, socioeconomic, and racial backgrounds were interviewed. Their responses were analyzed carefully, and each participant was interviewed a second time to validate recurrent themes regarding their statements about health. Results of the interviews with the three different groups of women were surprisingly similar. Although each participant had a unique application of their definition of health, there were five recurrent themes identified by 75% to 80% of the women. The themes were interactions with a being greater than themselves, acceptance of self, humor, flexibility, and being other-centered. Numerous examples supported the five themes. In addition, several "healthy behaviors" also were identified. Based on the findings of this 3-year study, older women seem to have their own perspectives on what health actually means and how they can best monitor or maintain their health. While the list is slightly different than the traditional one prescribed by health care professionals, perhaps it is time to encourage older adults to become more of a partner in their care. These healthy behaviors could be incorporated easily into the treatment and management plans and thereby reflect both parties' definitions of what it means to be healthy. Health care professionals must continue to ask older adults about their view of health and encourage their partnership in health-related issues. All individuals, no matter what age, are being encouraged to assume more responsibility for their own personal health, and by including older adults in the decision-making process, this partnership can be strengthened.

Positive approaches to dementia care in the home.

Healthcare providers must select appropriate interventions for dementia patients as they assist families in the struggle to understand the changes in loved ones and to learn how to effectively manage the caregiving challenges. This Dementia Care Program prescribes appropriate strategies for the patient's remaining functional abilities as cognition declines. The interdisciplinary approach of nursing and occupational therapy allows for a careful assessment and the use of strategies designed to facilitate optimal function and prevent or reduce behavioral disturbances common in dementia patients. Use of the Allen Cognitive Levels provides a framework that permits more precise care plans and more successful interventions for both professionals and families who care for those with dementing disorders.