Inferior Healing Rate in Isolated Meniscal Repair than that in Meniscal Repair with Concomitant ACL Reconstruction Evaluated with MRI.

Introduction: Isolated meniscal repair has been suggested as one of the contributing factors in unhealed meniscal repair. The purpose of this study was to compare the healing rate between isolated meniscal repair and meniscal repair with concomitant anterior cruciate ligament reconstruction (ACLR) using a standardised assessment method after propensity score matching. Materials and methods: Accuracy of the Crues' grading system for meniscal healing was validated using second-look arthroscopy as the reference standard in 17 patients. Propensity score matching (one-to-one) was performed between 26 patients who underwent isolated meniscal repair and 98 patients who underwent meniscal repair with concomitant ACLR. Patients were matched for sex, age, side and zone of the meniscal repair, and number of sutures. Healing rates at one year which were evaluated with magnetic resonance imaging (MRI) were compared between the two groups. Results: The sensitivity and specificity of the Crues' grading system on multiple plane MRI for meniscal healing were 100% and 83.3%, respectively. Both the isolated meniscal repair group and the meniscal repair with concomitant ACLR group included 21 patients after propensity score matching. Baseline characteristics did not differ significantly between the two groups. The healing rate was significantly lower in the isolated meniscal repairs group (14.3%) than in the meniscal repair concomitant with ACLR group (47.6%, P=0.04). Conclusion: The healing rate for isolated meniscal repair using a standardised MRI assessment method was inferior to that of meniscal repair with concomitant ACLR after propensity score matching.

Inferior Healing Rate in Isolated Meniscal Repair than that in Meniscal Repair with Concomitant ACL Reconstruction Evaluated with MRI

@#Introduction: Isolated meniscal repair has been suggested as one of the contributing factors in unhealed meniscal repair. The purpose of this study was to compare the healing rate between isolated meniscal repair and meniscal repair with concomitant anterior cruciate ligament reconstruction (ACLR) using a standardised assessment method after propensity score matching. Materials and methods: Accuracy of the Crues' grading system for meniscal healing was validated using second-look arthroscopy as the reference standard in 17 patients. Propensity score matching (one-to-one) was performed between 26 patients who underwent isolated meniscal repair and 98 patients who underwent meniscal repair with concomitant ACLR. Patients were matched for sex, age, side and zone of the meniscal repair, and number of sutures. Healing rates at one year which were evaluated with magnetic resonance imaging (MRI) were compared between the two groups. Results: The sensitivity and specificity of the Crues' grading system on multiple plane MRI for meniscal healing were 100% and 83.3%, respectively. Both the isolated meniscal repair group and the meniscal repair with concomitant ACLR group included 21 patients after propensity score matching. Baseline characteristics did not differ significantly between the two groups. The healing rate was significantly lower in the isolated meniscal repairs group (14.3%) than in the meniscal repair concomitant with ACLR group (47.6%, P=0.04). Conclusion: The healing rate for isolated meniscal repair using a standardised MRI assessment method was inferior to that of meniscal repair with concomitant ACLR after propensity score matching.

Inhibition of fibrotic changes in infrapatellar fat pad alleviates persistent pain and articular cartilage degeneration in monoiodoacetic acid-induced rat arthritis model.

OBJECTIVE: We have reported that fibrotic changes in infrapatellar fat pad (IFP) after acute joint inflammation are closely associated with persistent pain in rats. In this study, to examine the effects of anti-fibrotic treatment on persistent pain, we used C-type natriuretic peptides (CNP) at the recovery phase after acute joint inflammation. DESIGN: Thirty-two male Wistar rats were used in this study. Monoiodoacetic acid (MIA) was injected intra-articularly to induce IFP fibrosis and persistent pain. CNP was injected after acute inflammatory phase in the same knee joint. Time-course pain-avoidance behavior tests and histological analyses were performed to examine the effects of CNP. RESULTS: Histological evaluations indicated that intra-articular injection of CNP inhibited fibrotic changes in IFP after acute inflammation. Incapacitance tests indicated that MIA injection into rat knee joint quickly decreased the percent weight on ipsilateral limb. In the vehicle group, the decrease was maintained up to day 28, suggesting that pain persistence occurred after acute inflammation (Day 0/Day 28, Est Dif -8.15, CI -10.78∼-5.53, Linear mixed-effect model). In contrast, the pain was alleviated in the CNP group after day 14 (Day0/Day 14, -0.51, -2.62-1.59). In addition, we observed significant improvement in the degree of articular cartilage degeneration at day 14 in the CNP group (OARSI score: vehicle 16.14 ± 4.37 vs CNP 6.87 ± 3.44, P < 0.01; Wilcoxon rank sum test). CONCLUSION: Fibrotic changes in IFP may play important roles in both persistent pain and articular cartilage degeneration.

Management of paediatric tuberculosis in provincial and district hospitals in Afghanistan.

Case detection, diagnosis and treatment of tuberculosis 1 B) in children are challenging issues vorldwide. This study in Afghanistan aimed to evaluate paediatric TB case management, including contact investigation, at health facilities where all diagnostic processes were available. In 7 out of 8 regions of the country 1 province was selected. Documents used for management of paediatric TB cases were reviewed in 15 distinct hospitals and 8 provincial hospitals in the selected provinces. The key issues which emerged were: a low suspect rate among total outpatients (0.4%) and a very low suspect rate among children aged < 5 years; low performance of suspect management (68.5% suspects received further examinations); low utilization of other diagnostic methods; a high early defaulter rate (14.0%); and insufficient coverage of contact management (74.0%). This survey indicated that the Afghanistan national TB programme needs to develop plans to improve the quality of diagnosis, suspect management and contact management in paediatric TB cases.

Management of paediatric tuberculosis in provincial and district hospitals in Afghanistan

Case detection, diagnosis and treatment of tuberculosis [TB] in children are challenging issues worldwide. This study in Afghanistan aimed to evaluate paediatric TB case management, including contact investigation, at health facilities where all diagnostic processes were available. In 7 out of 8 regions of the country 1 province was selected. Documents used for management of paediatric TB cases were reviewed in 15 distinct hospitals and 8 provincial hospitals in the selected provinces. The key issues which emerged were: a low suspect rate among total outpatients [0.4%] and a very low suspect rate among children aged < 5 years; low performance of suspect management [68.5% suspects received further examinations]; low utilization of other diagnostic methods; a high early defaulter rate [14.0%]; and insufficient coverage of contact management [74.0%]. This survey indicated that the Afghanistan national TB programme needs to develop plans to improve the quality of diagnosis, suspect management and contact management in paediatric TB cases

Association of genetic variants for susceptibility to obesity with type 2 diabetes in Japanese individuals.

AIMS/HYPOTHESIS: In populations of East Asian descent, we performed a replication study of loci previously identified in populations of European descent as being associated with obesity measures such as BMI and type 2 diabetes. METHODS: We genotyped 14 single nucleotide polymorphisms (SNPs) from 13 candidate loci that had previously been identified by genome-wide association meta-analyses for obesity measures in Europeans. Genotyping was done in 18,264 participants from two general Japanese populations. For SNPs showing an obesity association in Japanese individuals, we further examined diabetes associations in up to 6,781 cases and 7,307 controls from a subset of the original, as well as from additional populations. RESULTS: Significant obesity associations (p < 0.1 two-tailed, concordant direction with previous reports) were replicated for 11 SNPs from the following ten loci in Japanese participants: SEC16B, TMEM18, GNPDA2, BDNF, MTCH2, BCDIN3D-FAIM2, SH2B1-ATP2A1, FTO, MC4R and KCTD15. The strongest effect was observed at TMEM18 rs4854344 (p = 7.1 × 10(-7) for BMI). Among the 11 SNPs showing significant obesity association, six were also associated with diabetes (OR 1.05-1.17; p = 0.04-2.4 × 10(-7)) after adjustment for BMI in the Japanese. When meta-analysed with data from the previous reports, the BMI-adjusted diabetes association was found to be highly significant for the FTO locus in East Asians (OR 1.13; 95% CI 1.09-1.18; p = 7.8 × 10(-10)) with substantial inter-ethnic heterogeneity (p = 0.003). CONCLUSIONS/INTERPRETATION: We confirmed that ten candidate loci are associated with obesity measures in the general Japanese populations. Six (of ten) loci exert diabetogenic effects in the Japanese, although relatively modest in size, and independently of increased adiposity.

Motor evoked potentials following transcranial magnetic stimulation after middle cerebral artery and/or basilar artery occlusions in rats.

To clarify the significance of motor evoked potentials following transcranial magnetic stimulation (MMEPs) in acute stage of cerebral ischemia, MMEPs were recorded in rats with the right middle cerebral artery (MCA) and/or the basilar (BA) artery occlusions. MMEPs from bilateral forelimb muscle and regional cerebral blood flow (rCBF) of the pons were recorded simultaneously. After MCA occlusion, the amplitudes of MMEPs from left forelimb were increased up to approximately 184-221% of the pre-ischemic value for 60 min, though the latencies were unchanged. On the other hand, in the rats of BA occlusion and both BA and MCA occlusion groups, MMEPs amplitudes were decreased to 8-25% of the pre-ischemic value for 60 min. Pontine rCBF was decreased to 28-44% in both groups. As a mechanism of the facilitation of MMEPs after MCA occlusion, the affection of the inhibitory mechanism between the cerebral cortex and the generator of MMEPs by MCA occlusion is speculated.

High frequency electrical stimulation attenuates progressive necrosis and cavitation following spinal cord injury.

This study evaluates the influence of preconditioning by following electrical stimulation on primary and secondary lesion formation following spinal cord injury in rats. The dorsal surface of the spinal cord was stimulated (500 Hz. 10 pulses/train, inter train interval of 10 sec. for 2 hrs) at the T7 level 24 hrs before a right side hemisection, carried out immediately after injury and maintained every 24 hrs for 7 days. Preconditioning by electrical stimulation of the spinal cord activates reactive astrocytes and significantly attenuates edema and progressive necrosis and cavitation, concerning especially the primary (1, 3 weeks post injury) and secondary (24 hrs, 1, 3 weeks post injury) lesion volume. The results suggest that pre-conditioning by electrical stimulation prevents spinal cord secondary lesion formation after injury, and that the beneficial effect is provided by astroglial cells with regard to their ability to attenuate trauma induced cellular cascades.

Involvement of the transforming growth factor-ß system in the pathogenesis of diabetic nephropathy.

The manifestation of diabetic nephropathy may be a consequence of the actions of certain cytokines and growth factors. Prominent among them is transforming growth factor-ß (TGF-ß), which promotes renal cell hypertrophy and stimulates extracellular matrix accumulation, the two hallmarks of diabetic renal disease. In experimental and human diabetes mellitus, several reports describe overexpression of TGF-ß in the glomeruli and tubulointerstitium. In renal cell cultures, hypertrophy and matrix production are stimulated by high glucose concentrations in the culture media. High glucose, in turn, appears to act through the TGF-ß system; high glucose increases TGF-ß expression, and the hypertrophic and matrix stimulatory effects of high glucose are prevented by anti-TGF-ß therapy. Short-term treatment with the same neutralizing monoclonal antibodies against TGF-ß in type 1 diabetic mice significantly reduces kidney weight and glomerular hypertrophy and attenuates the increase in extracellular matrix mRNA. Similar treatment of type 2 diabetic mice in the long term further diminishes the renal pathology and ameliorates the functional abnormalities of diabetic nephropathy. Finally, the intrarenal TGF-ß system is significantly up-regulated in human diabetes. Whereas the kidney of a nondiabetic subject extracts TGF-ß1 from the circulation, the kidney of a diabetic patient elaborates TGF-ß1 protein into the circulation. The data we review here strongly support the hypothesis that elevated production or activity of the TGF-ß system mediates diabetic renal hypertrophy and extracellular matrix expansion.

The key role of the transforming growth factor-beta system in the pathogenesis of diabetic nephropathy.

Progressive renal injury in diabetes mellitus leads to major morbidity and mortality. The manifestations of diabetic nephropathy may be a consequence of the actions of certain cytokines and growth factors. Prominent among these is transforming growth factor-beta (TGF-beta) because it promotes renal cell hypertrophy and stimulates extracellular matrix accumulation, the two hallmarks of diabetic renal disease. In cell culture, high ambient glucose increases TGF-beta mRNA and protein in proximal tubular, glomerular epithelial, and mesangial cells. Neutralizing anti-TGF-beta antibodies prevent the hypertrophic and matrix stimulatory effects of high glucose in these cells. In experimental and human diabetes mellitus, several reports describe overexpression of TGF-beta in the glomeruli and tubulointerstitium. We demonstrate that short-term treatment of diabetic mice with neutralizing monoclonal antibodies against TGF-beta significantly reduces kidney weight and glomerular hypertrophy and attenuates the increase in extracellular matrix mRNAs. Long-term treatment of diabetic mice further improves the renal pathology and also ameliorates the functional abnormalities of diabetic nephropathy. Finally, we provide evidence that the renal TGF-beta system is significantly up-regulated in human diabetes. The kidney of a diabetic patient actually elaborates TGF-beta1 protein into the circulation whereas the kidney of a non-diabetic subject extracts TGF-beta1 from the circulation. The data we review here strongly support the hypothesis that elevated production or activity of the TGF-beta system mediates diabetic renal hypertrophy and extracellular matrix expansion.

Clinical features of symptomatic Rathke's cleft cyst.

To investigate the clinical features of Rathke's cleft cysts (RCCs), we retrospectively analyzed 15 cases with histologically confirmed RCCs. All patients underwent formal testing of visual field, endocrinological evaluation and magnetic resonance imagings. As overall presenting symptoms, endocrine disturbance was the most common symptoms, followed by visual disturbance and headache. Among the endocrine disturbances based on adenohypophysial dysfunction, hyperprolactinemia was most common. Considering the size of RCCs, RCCs could induce hyperprolactinemia only when the cysts became large enough to compress the infundibular system. Our series showed relative high incidence of pituitary dwarfism and diabetes insipidus (DI). These facts indicated that RCCs could evoke hyposecretion of growth hormone in young patients and DI in aged patients by direct compression of the pituitary gland in the early stage of progression. All cases who had headache had no other symptoms. We could not prove the evidence that RCCs could induce headaches in these cases. This might be suggested that headache could not be a sole symptom in cases of RCCs.

Increased glomerular and tubular expression of transforming growth factor-beta1, its type II receptor, and activation of the Smad signaling pathway in the db/db mouse.

Activation of the renal transforming growth factor-beta (TGF-beta) system likely mediates the excess production of extracellular matrix in the diabetic kidney. To establish the role of the TGF-beta system in type 2 diabetic nephropathy, we examined the intrarenal localization and expression of the TGF-beta1 isoform, the TGF-beta type II receptor, and the Smad signaling pathway in the 16-week-old db/db mouse, a genetic model of type 2 diabetes that exhibits mesangial matrix expansion, glomerular basement membrane thickening, and renal insufficiency that closely resemble the human disease. Compared with its nondiabetic db/m littermate, the db/db mouse showed significantly increased TGF-beta1 mRNA expression by in situ hybridization in both glomerular and tubular compartments. Likewise, TGF-beta1 protein, by immunohistochemical staining, was increased in both renal compartments, but the fractional expression of TGF-beta1 protein was less than that of the mRNA in the glomerulus. In situ hybridization and immunohistochemical staining for the TGF-beta type II receptor revealed concordant and significant increases of both mRNA and protein in the glomerular and tubular compartments of diabetic animals. Finally, immunohistochemistry showed preferential accumulation of Smad3 in the nuclei of glomerular and tubular cells in diabetes. The complementary technique of Southwestern histochemistry using a labeled Smad-binding element demonstrated increased binding of nuclear proteins to Smad-binding element, indicating active signaling downstream of the TGF-beta stimulus. We therefore propose that the TGF-beta system is up-regulated at the ligand, receptor, and signaling levels throughout the renal cortex in this animal model of type 2 diabetes. Our findings suggest that the profibrotic effects of TGF-beta may underlie the progression to glomerulosclerosis and tubulointerstitial fibrosis that characterize diabetic nephropathy.

Midaortic syndrome in childhood associated with a ruptured cerebral aneurysm: a case report.

BACKGROUND: We present a patient with a midaortic syndrome who presented with subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm. CASE DESCRIPTION: A 14-year-old boy with midaortic syndrome was admitted to our hospital because of subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. He also developed acute renal failure due to previously controlled hypotension. After blood dialysis, successful clipping of the aneurysm was performed. The postoperative course was complicated by malignant renovascular hypertension due to midaortic syndrome. Medical treatment failed to control his hypertension; left primary nephrectomy improved his condition. CONCLUSION: Although midaortic syndrome is rare, it may be significant as a cause of cerebral hemorrhage in childhood.

Retro-odontoid soft tissue mass associated with atlantoaxial subluxation in an elderly patient: a case report.

BACKGROUND: We present the case of an elderly patient with a retro-odontoid soft tissue mass associated with atlanto-axial subluxation. CASE DESCRIPTION: A 74-year-old man was admitted to our hospital with progressive motor weakness in his right arm and neck pain. Radiological examinations revealed atlantoaxial subluxation and diffuse degenerative changes. Cervical MRI revealed a syrinx at the C1 level and a retro-odontoid soft tissue mass that severely compressed the spinal cord. The mass was of low signal intensity on both T1- and T2-weighted images. Conservative therapy could not stop the progression of his symptoms, so posterior decompression via a laminectomy of C1 and occipitocervical fixation was performed. These procedures resulted in an improvement of his neurological condition and in reduction of the mass and the compression of the spinal cord. CONCLUSION: The patient lacked any specific conditions that might have caused chronic atlantoaxial subluxation. The degenerative changes alone might have provoked chronic atlantoaxial subluxation and a subsequent retro-odontoid soft tissue mass. In patients with this condition, posterior fixation without direct removal of the mass should be the first choice for surgical intervention.

Leptin stimulates type I collagen production in db/db mesangial cells: glucose uptake and TGF-beta type II receptor expression.

BACKGROUND: Serum leptin levels correlate with fat cell mass and are elevated in patients with massive obesity and type 2 diabetes mellitus, which are strong risk factors for the development of glomerulosclerosis. We have previously shown in cultured glomerular endothelial cells that leptin stimulates cellular proliferation and expression of the prosclerotic cytokine transforming growth factor-beta1 (TGF-beta1). Although the effect of leptin on the hypothalamus to regulate energy homeostasis is well known, the effect of leptin on the kidney, and specifically on the glomerular mesangial cell, is unclear. METHODS: The obese, diabetic db/db mouse, which lacks the functional full-length Ob-Rb leptin receptor, is a suitable model to assess the effects of hyperleptinemia on peripheral tissues that express other receptor isoforms. The effects of leptin on glucose uptake, the TGF-beta system, and type I collagen production were evaluated in db/db mouse mesangial cells in culture. A phosphatidylinositol-3 kinase (PI-3K) inhibitor was used to assess the role of PI-3K in mediating the effects of leptin. RESULTS: A short form of the leptin receptor (Ob-Ra), but not Ob-Rb, was present by reverse transcription-polymerase chain reaction in the kidney and mesangial cells of both nondiabetic db/m and diabetic db/db mice. In db/db mesangial cells, leptin increased 2-deoxy-D-glucose (2DOG) uptake dose dependently and stimulated gene expression of TGF-beta type II receptor (TbetaRII) and alpha1(I) collagen, but not TGF-beta1. Protein production of type I collagen (enzyme-linked immunosorbent assay) was also increased by leptin. Both leptin-stimulated 2DOG uptake and type I collagen production were suppressed by a PI-3K inhibitor, LY294002. Mesangial cells pretreated with leptin exhibited increased responsiveness to exogenous TGF-beta1, as evidenced by a greater production of type I collagen protein in leptin-pretreated cells exposed to low-dose TGF-beta1 (0.5 ng/mL). The addition of both TGF-beta1 (2 ng/mL) and leptin (100 ng/mL) increased type I collagen production more than addition of either TGF-beta1 or leptin alone. CONCLUSIONS: Leptin increases glucose uptake and type I collagen in db/db mesangial cells through a PI-3K-dependent pathway. We postulate that increased leptin levels may transmit a signal through the short-form leptin receptor to up-regulate TbetaRII and activate the intraglomerular TGF-beta system, which may contribute to the glomerulosclerosis of obesity or type 2 diabetes.

Adenovirus-mediated hepatocyte growth factor gene transfer prevents lethal liver failure in rats.

Hepatocyte growth factor (HGF) has a potent antiapoptotic effect on hepatocytes in D-galactosamine (D-GalN)/lipopolysaccharide (LPS)-treated rats. Here, we report that adenovirus mediated HGF gene transfer into liver prevents liver failure and reduces mortality of rats treated with d-GalN/LPS. Fisher 344 rats, which were given intraperitoneal injections of pAxCAHGF 48 h before, were treated with D-GalN/LPS. Serum ALT in the HGF group at 6 and 12 h after D-GalN/LPS was decreased to 1/6 and 1/12 of the control group (P < 0.01, each). Concomitant reduction of apoptotic cells were also observed. The Kaplan-Meier analysis showed that a survival rate in the HGF group was improved, compared to that in the control group (P < 0.05). Caspase-3 activity in the HGF group decreased, compared to that in the control group, especially at 12 h (P < 0.05), although it maintained a high level in the control group. Expression of Bcl-xL and cyclooxygenase-2 (Cox-2) was induced in liver by HGF gene transfer. These data suggest that HGF exerts an antiapoptotic effect through dual induction of Bcl-xL and Cox-2, which suppresses caspase-3 activity.

[Reliability of electrogustatory threshold--electrogustometry using CNV].

CNV (contingent negative variation), an event-related potential, is induced when an oncoming imperative stimulus (S2) is anticipated after recognition of a warning stimulus (S1). With this in mind, we assessed the usefulness of electrogustometry using CNV as an objective gustatory test with an electric gustatory stimulus as a warning stimulus, S1. A gustatory test was performed on a total of 100 sides of the tongue in 50 subjects. Excluding no response cases on 5 sides in 5 subjects, the CNV threshold was successfully determined on 95 sides in 50 subjects. When the CNV threshold values obtained and the conventionally measured subjective threshold values were compared, a very high correlation was demonstrated between the two thresholds, with a correlation coefficient of 0.961. To assess the reliability of the CNV threshold, three additional measurements on 5 sides in 5 subjects with normal subjective threshold values were performed on different days, and the CNV threshold value variation among the three measurements in all 5 subjects never exceeded 13 microA. Separately, subjective threshold and CNV threshold values were compared in 4 patients with facial palsy (hence with gustatory abnormality) who consented to a follow-up examination. The difference between the subjective threshold and CNV threshold values in all 4 patients never exceeded 10 microA. These findings demonstrate that the reliability of the CNV threshold is satisfactory. Next, a gustatory imitation experiment was performed to assess the usefulness of electrogustometry using CNV as a means of detecting gustatory abnormality malingering. The experiment was performed on a total of 6 subjects: 3 physicians with knowledge of CNV (knowledge group) and 3 others with no knowledge of CNV (no-knowledge group). The differences between the imitated threshold and the subjective threshold values in all of these subjects never exceeded 10 microA, and the difference between imitated threshold and CNV threshold values never exceeded 13 microA. Comparison between the knowledge group and the no-knowledge groups showed that the imitated threshold values were very close to the subjective threshold and CNV threshold values. Based on the above results, it was concluded that gustometry using CNV is useful and can serve well as a method of objective evaluation of gustatory sensation. The results also suggested that it will be useful in diagnosing malingering.

Attempted gene therapy for intractable pain: dexamethasone-mediated exogenous control of beta-endorphin secretion in genetically modified cells and intrathecal transplantation.

For optimal neural transplantation using gene engineering, it might be important to control the expression of the transfected gene extrinsically as required. This strategy could be very useful for the treatment of intractable pain that responds to opioids. For this purpose, we established a genetically modified embryonal carcinoma cell line (P19) in which the expression of beta-endorphin (beta-EP) could be controlled by the addition of dexamethasone. To obtain extrinsic control, we transfected the cells with pMAMneo containing mouse MMTV-LTR as a promoter and cDNA of the artificial beta-EP. The upregulation of beta-EP, through the activation of MMTV by the administration of dexamethasone, was confirmed in vitro. Then we transplanted these cells into the subarachonoid space in rats and evaluated the analgesic potential of these cells in vivo by hot plate test and formalin test. In the rats that received beta-EP-producing cells, we observed prominent analgesic effects after the transplantation for a month. The administration of naloxone blocked these effects. Intraperitoneal injection of 100 mg/kg dexamethasone further enhanced these effects by up to two times. These data indicate obvious analgesic effects of the cells after the transplantation and the possible exogenous upregulation of transfected beta-EP gene expression in vivo. The application of this technique might provide a new therapeutic approach to various neurological diseases.