br Discussion A cut point of was

A cut-point of 5 was recommended in a previous study using the English version. The reason for this Autophagy Compound Library discrepancy is not clear, but backgrounds of the study subjects may affect cut-points. In addition to the difference between Asian and Western populations, the present study is population-based while patients from general practice and specialist sites were involved in the previous report. In this study, a cut-point of 5 resulted in a lower sensitivity of 34.9% and a smaller area under the ROC curve of 0.57 compared with a cut-point of 4.
Although the use of spirometry at all levels of health care might improve diagnosis and detect COPD earlier, widespread spirometric testing for early detection without pre-selection of at-risk patients may result in wasting healthcare resources. Without bronchodilator, 11.2% of adults aged between 40 and 79 years showed an initial FEV1/FVC < 0.7, and this prevalence is in line with the previous Japanese COPD epidemiology study conducted in 2001. Finally, 6.5% had confirmed fixed AO after bronchodilator in this study, and the COPD-PS and its cut-point of 4 resulted in a positive predictive value 14.6%. The prevalence of fixed AO was lower than expected. Aging increases the prevalence of COPD. The chosen target group in our study was aged 40–79 years, and this age limit may affect the prevalence of AO. We also excluded the subjects with physician-diagnosed asthma, which contains current- and former-smokers, and thus may preclude subjects with overlap syndrome of COPD and bronchial asthma.
A PPV of 14.6% at COPD-PS cut-point 4 is lower than the previous report of a hospital/clinic-based study. However, PPV depends on the prevalence, and PPV becomes lower when the prevalence of disease is low. The hospital/clinic-based prevalence will vary by age and smoking prevalence. In contrast, we have evaluated the diagnostic cut-points of the COPD-PS in the general Japanese population. The prevalence of confirmed fixed AO was 38.4% in the previous report, and that was 6.5% in the present study. Despite this limitation, NPV was sufficiently high in this study, suggesting that COPD-PS with cut-point 4 is useful for a screening tool.
This study has limitations that should be acknowledged. Subjects over the age of 60 and have smoked more than 100 cigarettes could reach 4 point without any respiratory symptoms. This could lead to an increase in false positives. As the objective of the COPD-PS is to be a diagnostic triage for spirometry testing, it is important to capture as many true positive COPD patients as possible, while allowing false positives to a certain degree. A considerable percentage of the nonsmoker population may exhibit COPD, and future studies evaluating a secondhand smoke item and indoor pollution at home may be of interest. In addition, AO was assessed based solely on the spirometry data, and further evaluations would be needed for the diagnosis of COPD.


This study was supported in part by Nippon Boehringer Ingelheim and Pfizer Japan, by a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS) (HI, 25293192), and by Health and Labour Sciences Research Grants from the Ministry of Health, Labour and Welfare of Japan. The sponsors did not have direct influence on the study design or analysis.

Japanese cedar pollinosis is an allergic disease specific to Japan with a high prevalence estimated to be 26.5%, which has increased by 10% over the past ten years. Seasonal allergic rhinitis induced by cedar pollen takes a chronic course in the majority of middle-aged patients. Remission rarely occurs, especially in the younger generation.
Sublingual immunotherapy (SLIT) is safer than conventional percutaneous antigen-specific immunotherapy, and is the only treatment which can completely cure the disease. It has been shown that SLIT is effective and safe in the treatment of cedar pollinosis by a randomized, placebo-controlled, double-blind study.

Adam investigated coupled bending and torsional vibrations of

Adam [12] investigated coupled bending and torsional vibrations of beams under forced vibration. He had solved the governing coupled set of partial differential equations by separating the dynamic response in a quasistatic and in a complementary dynamic response and getting the generalized decoupled single-degree-of-freedom (DOF) oscillators by means of Duhamel’s convolution integral. Zhao et al. [13] a Jeffcott rotor model with imbalance -crack- was held he investigated the coupling of lateral and longitudinal vibration by using D’Alembert Principle. His model was approximated to four DOF. To solve his model, he used the stiffness matrix method. Moreover, the breathing behavior of the crack under axial excitation is studied in terms of several eccentricity phases and rotation speeds.
The finite dgat inhibitor method (FEM) and the transfer matrices (TM) also are used. Papadopoulos and Dimarogous [14] did a comprehensive investigation on many kinds of the coupled vibration in the cracked shaft system by FEM. Wu and Yang [15] deduced a computer technique for forced coupled torsional-flexural vibration of shafting system with damping, where the eccentricity of the locus of the mass centers had been taken into consideration. In their study, a discrete model with multi-degrees of freedom (MDOF) is applied. Qing and Cheng established the finite element model of coupled torsional-flexural vibration of shaft system, and the properties of coupled vibration were studied by combining FEM, TM and impedance method by Qin and Mao [16,17] established. El-Saeidy [18,19] showed a formulation in FEM for the dynamic analysis of a rotating shaft with or without nonlinear characteristics under the action of a moving load.
Katz [20] studied the dynamic response of a rotating shaft subject to moving and rotating loads. In addition, he presented an analytical expression for this response. Huang and Yang [21] continued [20] work and simulated a lathe machine as a rotating Rayleigh beam and showed that the presence of the axial moving force can yield one major instability region for each vibration mode. Although Katz, Huang, and Yang work is much related to the present work, they didn’t give a good estimation for the internal torsional resistance and just studied the dynamic response as presented here.

Model description
The experimental setup is shown in Fig. 1 and a photograph of the apparatus is shown in Fig. 2

Results and discussion

It was found that

The use of photovoltaic device has been growing so rapidly to utilize the world’s amplest energy source, incident sunlight. And in recent years the and the , the promising absorber layer materials, have drawn much attention to the photovoltaic researchers for highly efficient and low-cost thin film solar cells [1–4]. Besides, the absorber-based solar cells expose more radiation severity, excellent stability and higher energy conversion efficiency of [2]. Despite having lower energy conversion efficiency than the most common absorbers, and based thin-film solar cells having the recorded efficiencies of and respectively [5], the solar cell has become an emerged photovoltaic absorber to the researchers because of its conductivity and tunable direct band gap of with a higher absorption coefficient of [6–10]. Moreover, comparing to the expensive and scarce indium , the global annual production of Zn and Sn is about and times more, and the availability is times and times higher [11]. And therefore, the mixed chalcogenide, has become a more emergent choice and a potential alternative to the and absorbers. However, an environment-friendly non-toxic zinc-tin-oxide material was also introduced as an alternative buffer layer to the conventional toxic buffer layer material [12]. Another reason beyond using buffer in thin film solar cell is that it has a wider energy band gap ranges from to [13,14], permitting the photons having a lower wavelength into the absorber and thus increasing the conversion efficiency.

Figs show demonstration of CT

Figs. 1–7 show demonstration of CT findings in seven patients included in this study.
Table 2 shows the different CT findings detected in the examined patients.

In the current study, MDCT exams were done considering the ALARA (‘as low as reasonably achievable’) general principles to minimize the radiation exposure to children while maintaining diagnostic image quality. Justification for the requested study and adjusting the CT parameters regarding the peak kilovoltage and tube current settings (mAs) to minimize the radiation dose delivered to the pediatric patients was also considered. These considerations matched with the guidelines of, Kalra et al., Shah et al., and McCollough et al., who stated that the pediatric radiologists should apply the practice of ALARA (‘as low as reasonably achievable’) to minimize radiation exposure to children while maintaining the efficiency and the reliability of the diagnostic modality by justification of the use of CT for the specific diagnostic task and considering the dose reduction strategies considering the scanning parameters of the pediatric protocols.
Ko et al., mentioned that on MDCT and MRI, the presence of a bowel-within bowel configuration with inclusion of mesenteric fat and/or mesenteric vessels is diagnostic for intussusception. However, in infants and children, these methods should be only used for complex diagnostic situations, when US is inconclusive or atypical, or when complications such as suspicion of an oncological disease require additional imaging which was the situation in the present study. Tseng et al., stated that both plain film X-rays and abdominal ultrasonography had lower diagnostic accuracies compared with MDCT of the abdomen and Pirfenidone in acute abdomen pediatric patients. This is matching with the present study in which plain radiography and ultrasonography failed to reach a complete diagnosis and CT was ordered to reach a complete diagnosis.
Ko et al., demonstrated that MDCT was 100% sensitive in the diagnosis of pediatric small bowel intussusception disease (SBID). CT also allowed detection of pathological lead points. Moreover, CT is also helpful in detection of other abdominal conditions, changing the diagnosis and treatment. It is also observed that the pediatric small bowel intussusception disease (SBID) may present with nonspecific symptoms and may be similar to that of ileocolic intussusception leading to delayed operative intervention. Navarro et al., and Linke et al., stated that less than 5% of intussusceptions in infants occur sequel to pathological lead points (PLPs) and this rate increases up to 60% in the 5- to 14-year age group. Intussusception has also been reported post-operatively. Also Ko et al., Carty and Strouse stated that the most common pathological lead points in intussusception are Meckel’s diverticulum, polyp, lymphoma, duplication cyst, cystic fibrosis, Henoch–Schönlein purpura and celiac disease. In the present study CT adequately detected the pathological leading points in all the examined patients. In four cases of lymphoma, the diagnostic findings included multiple pathologically enlarged abdominal lymph nodes, one of them showed an intestinal mural thickening and soft tissue intestinal mass lesion. Multiple reactive mesenteric lymph nodes were detected in three cases associated with bowel intussusception without definite specific signs for lymphoma histopathology after surgery confirmed the absence of lymphoma. A case of mesenteric lymphangioma, showed thin walled multiloculated cystic mesenteric lesion forming a leading point for an ileo-colic intussusception associated with marked fluid collection. In a case of malrotation, the duodeno-jejunal junction was noted on the right side of the vertebral column which was associated with jejuno-jejunal intussusception with the invagination of the head of the pancreas into it. In a patient diagnosed with Henoch–Schönlein purpura an intramural hematoma as an initial mural hyperdensity in the bowel wall in the pre-contrast image formed a leading point for an ileo-ileal intussusception. One patient was diagnosed with Meckel’s diverticulum, the site the of the ileo-ileal intussusception at the mid lower abdomen was the key finding for diagnosis.

In mammals the hypothalamus is the

In mammals, the hypothalamus is the unique Z-IETD-FMK manufacturer region orexin neurons are restricted to, but brain anatomy shows an important distribution of orexin neurons, and many brain regions, in addition to other extra cerebral structures, have orexin neuron fibers including the median eminence, arcuate nucleus, pituitary, olfactory bulb, cerebral cortex, thalamus subfornical organ, area postrema, hippocampus, amygdala, indusium griseum, brainstem and spinal cord, thus pharmacological benefits of targeting orexinergic neurons might be extended into those structures in the future.
Orexinergic neurons, that form a unique central orexinergic system, project to regions associated with different cerebral functions such as reward, learning and memory, emotion and attention, supposing a possible modification of these functions by orexin receptors’ ligands, either as an eventual therapeutical approach or as a side effect of orexin receptors’ ligands. Importantly, interactions of the orexinergic system with other neurotransmitters have also been reported. For instance, in anesthetized rats, the activation of orexin neurons can be obtained via a local disinhibition of neurons of perifornical region of the posterior hypothalamus neurons by GABA (A) receptor antagonists. Interestedly, the implication of orexin A and orexin B in the regulation of monoaminergic and cholinergic neuron function in wakefulness maintenance has also been reported. Furthermore, orexin application to the rat brain produces serotonergic and cholinergic neuron depolarization, and orexin has been shown to modify the synaptic activity of dopamine neurons. Moreover, a recent publication has shown that the increase of glutamatergic synaptic transmission in the ventral tegmental area (VTA) has been linked to OX2R activity. Finally, whereas OxA/hcrt-1N-methyl-d aspartate receptor (NMDAR)-mediated synaptic transmission of dopamine neurons in the VTA has also been reported, intra-VTA administration of oxA/hcrt-1 results in an increased local dopamine and glutamate release. These interactions between the orexinergic system and other neurotransmitters could be exploited either to a better understanding of the orexinergic system underlying pathways or to develop more selective drugs. At the same time such interactions can lead to complex side effects of the orexinergic receptors’ ligands.
Based on the orexin related-pharmacological properties, pharmaceutical companies are trying to develop drugs that target orexin receptors, mainly to treat sleep disorders. It was reported that small molecule orexin receptor antagonists can help patients suffering from insomnia by promoting sleep. Herein, we state some orexin receptors’ ligands that have been either pointed in clinical trials or that may be effective for insomnia treatment. SB-334867 constituted the most often used orexinergic antagonist in the literature. Whereas SB-649868 constitutes an emerging antagonist in development by GlaxoSmithKline, a new selective and highly potent spiropiperidine-based OX2R antagonist was discovered in 2011. On the other hand, several papers have pointed to the two orexin receptor antagonists: suvorexant and almorexant (or ACT-078573), these small molecules have, in addition to their ability to promote sleep in animals, clinical efficacy. Furthermore, for the treatment of primary insomnia, the phase III of clinical trials of suvorexant has been completed. Previously suvorexant, considered as the most advanced dual orexin receptor antagonist (DORA), was reported to induce sleep in humans with analogous potency toward both OX1R and OX2R. Among suvorexant, MK-6096 (a piperidino-derived) and DORA-22 that are dual orexin receptor antagonists (DORAs), MK-6096 and DORA-22 show a high selectivity for OX1R and OX2R therefore, have the pharmacological properties to decrease wakefulness and thus, represent potential agents for sleep/wake dysregulation treatment.
Previously, eszopiclone (ESZ), a cyclopyrrolone targeting GABA-A receptor, was pointed to suppress orexinergic neurons’ activity with a possible use in insomnia treatment. This datum gets its importance from the fact that many hypnotic agents target GABA-A receptor, which strengthens the theory that links orexin system to insomnia. Another class of orexin 2 antagonists, that includes 2-methyl-3-furanyl-4H-1,2,4-triazol-3-ylthioamides, has been described as well. Pharmacokinetics described different routes of administration of orexin receptors’ antagonists. For instance, almorexant can be administered orally, while SB-334867 can be injected systemically, thus gives a clinical use flexibility of such drugs.

Introduction In the Shah of Iran Mohammad

In 1980, the Shah of Iran, Mohammad Reza Pahlavi died of cancer, and only nine months after, the medical correspondent of the New York Times, Dr. Altman wrote: “Even today… some of the physicians who were intimately involved in the case still debate several critical points in the Shah’s medical care.” 30years after the Shah’s death, this debate is still ongoing. Unfortunately, few books and articles have been written that discuss the Shah in light of his health and the chaos that surrounded it. Some of them even contain false or incomplete information: for example, that the Shah had been treated at the Mayo Clinic or that the State Department had no real information about the Shah’s condition. Only the British journalist William Shawcross and the late Dr. Leon Morgenstern have earlier given detailed accounts of the Shah’s disease; hence, there is still a knowledge gap regarding the Shah’s health care and the political aspects of it.
Considering the growing interest in the person of the Shah, not least in Iran and among the youth, there is a need for amalgamating all available information and accounts to reveal details, not only of the Shah’s health, but also the political questions surrounding it. Through a review of relevant literature, we here present an account of what happened to the Shah, from diagnosis to his death. An invaluable source for this article has been the letters of Professor Georges Flandrin to his teacher, Professor Jean Bernard, published in the memoirs of Queen Farah Pahlavi. These letters document in detail, Flandrin’s many clandestine visits to Iran, and the condition of the Shah’s health.

The spleen
In discussing the onset and time for diagnosis of the Shah’s disease, one school of thought deems that the Shah developed symptoms and was diagnosed in 1973/4, while another considers that it cam kinase ii was earlier. The most detailed information about the Shah’s symptoms was probably recorded by the Shah’s former Minister of Court, Asadollah Alam, who kept a diary of all of their meetings. On noticing a swelling in the left upper abdomen on April 9, 1974, the Shah called upon his personal physician, Dr. Ayadi who diagnosed the Shah with a splenomegaly. After examination, Ayadi asked Alam to call upon the French hematologist, Professor Jean Bernard. Alam contacted Professor Safavian, who would later join the Shah’s medical team, who took contact with Bernard whom he knew from his time in Paris as a medical student and later as a physician. With Bernard not available, the Shah decided to wait until his annual checkup in Vienna by Professor Fellinger. The diary mentions nothing about a possible earlier diagnosis or symptoms before April 9, which is curious, since the Queen writes that the Shah had symptoms in the autumn of 1973.
Later, in April, the Shah met Fellinger, and, according to the historian Andrew Cooper, the Shah was informed that he had lymphoma. Alam had kept in contact with Bernard who, on May 1, 1974, left France for Tehran together with Professor Georges Flandrin. They met Safavian at the airport who showed them to the Hilton Hotel and then left. There, they were informed by Alam that their patient was the Shah. According to Safavian, but contradicted by Flandrin and other literature reviewed, also the renowned French physician, Professor Milliez was present. Until the Shah’s departure from Iran in January 1979, he would meet Flandrin a total of 39 times, 35 of them in Iran. During this first visit, the Shah was examined and diagnosed with chronic lymphocytic leukemia. Ayadi insisted that this information must not be revealed to the Shah, a request respected by his French counterparts. Several blood samples were taken back to France, which showed the presence of a so-called monoclonal immunoglobulin M peak, characteristic of Waldenström’s disease. Being an indolent lymphoma, Fingerprint of DNA was the perfect diagnosis to give the Shah; one in accordance with Ayadi’s wish to avoid using the term cancer. With the samples analyzed, the physicians decided to merely supervise the Shah, without providing any specific treatment.

fasudil Dimensionless temperature profiles inside the boundary layer and its gradients

Dimensionless temperature profiles inside the boundary layer and its gradients for different m while are displayed in Fig. 4a and b. As m grows, temperature gradients inside the boundary layer increases; consequently, heat transfer rate increases as well. Further, it is seen that m affects negative values of more noticeably. Clearly, the absolute values of temperature gradients increase in the transverse direction; this trend reduces as m increases. With this in mind, regarding to Fig. 4a, it can be concluded that size of zone 1 has direct effects on this trend.
Fig. 5a and b present the fasudil generation rate inside the boundary layer for and respectively. As it can be seen after a gentle rise in the generated entropy, it takes a decreasing trend and finally vanishes which can be explained as follows: at the vicinity of the wall, thermal and velocity gradients are almost constant. Thus, moving outward from the wall, the values of θ decreases gradually; however, the generated entropy increases manifestly. As previously stated, the higher gets, the distance between the critical point (C) and the surface increases and the constant velocity gradient area gets longer, therefore, the maximum point of the generated entropy gets closer to the surface. Needless to say that in the case , due to transverse momentum near the interface of zones 1 and 2 (Fig. 1) we can see a noticeable rise for .
To consider the effects of temperature gradients and friction forces on entropy generation, Bejan number is plotted inside the boundary layer in Fig. 6a and b. Obviously, which states that has a higher contribution on the total entropy generation. Near the wall where viscous forces are governed, impact of gets more obvious and Be reduces; on the flip side, far away from the wall, the contribution of in total entropy generation diminishes and Be increases. There is no need to say that for Pr<1 (Here Pr=0.72) the temperature profile is thicker than the hydrodynamic profile. Therefore, as η approaches to the hydrodynamic boundary layer thickness, the velocity gradient vanishes, however, the thermal boundary layer (region of temperature gradients) still exists. Hence, the temperature gradients are the only source of the generated entropy (=0) and Be approaches to unity for the higher values of η. Increasing m, intensifies the viscous effects near the walls and Be reduces more there. This reduction is more pronounced for , in which the wedge moves in the opposite direction of the free stream.
The reduced skin friction coefficient has been plotted in Fig. 7. Not surprisingly, at this coefficient vanishes since there is no shear stress. Moreover, the reduced skin friction coefficient depends on the value of . Positive and negative reduced skin friction coefficient corresponds to and respectively. Considering the Physical aspects, the negative sign of the reduced skin friction coefficient indicates that the moving wedge exerts a drag force on the fluid and the positive sign implies the opposite. Needless to say, the reduced skin friction coefficients reach its maximum point when .
Fig. 8 shows the values of reduced Nusselt number versus . It can be realized that when increases, the heat transfer coefficient grows as well. Comparing the cases and it can be seen that in the first case, Nusselt number experiences more changes. Effects of , on the total entropy generation is plotted in Fig. 9. It is obvious that increasing in m increases the generated entropy. Considering the possibility of existence a case with minimum entropy generation, we have found that there is an optimum value of , say , which minimizes the entropy generation for each m. It is worth mentioning that the higher m gets, the absolute values of increases which is presented for different wedge angles in Table 3.

One knows that how consequential is the thermodynamic optimization of systems nowadays. This survey deals with the minimization of entropy generation inside the boundary layer over a moving wedge. In fact, this idea is a new point of view to the well-known Flakner–Skan problem. The transformed ODE equations have been solved with the Runge–Kutta–Fehlberg scheme as a reliable numerical technique. Optimization the flow over a moving wedge inside the boundary layer as the target, an appropriate relation is then presented and solved. The main results of the paper can be summarized as follows:

Introducing the following non dimensional quantities

Introducing the following non-dimensional quantities
Using the transformations (8), the non-dimensional forms of (1), (3) and (7) are
The corresponding initial and boundary conditions are

Method of solution
The unsteady, non-linear, coupled partial differential Eqs. (9)–(11) along with their boundary conditions (12) have been solved analytically using usual Laplace transform technique and the solutions for hydromagnetic flow in the presence of radiation and porosity of the medium are obtained as follows:

Skin friction
The boundary layer produces a drag force on the plate due to the viscous stresses which are developed at the wall. The viscous stress at the surface of the plate is given by

Numerical technique
In order to solve the unsteady, non-linear coupled Eqs. (9)–(11) under the conditions (12), an implicit finite difference scheme of the Crank–Nicolson type has been employed. The finite difference equations corresponding to Eqs. (9)–(11) are as follows:
The region of integration is considered as a rectangle with sides (=1) and (=14), where corresponds to y=∞ which lies in the momentum and syk inhibitors boundary layers. The maximum of y is chosen as 14 after some preliminary investigations so that the last two of the boundary conditions (14) are satisfied within the tolerance limit 10−5. After experimenting with a few set of mesh sizes, the mesh sizes have been fixed at the level Δy=0.25 with time step t=0.01. In this case, the spatial mesh sizes are reduced by 50% in one direction, and later in both directions, and the results are compared. It is observed that, when the mesh size is reduced by 50% in the y-direction, the results differ in the fifth decimal place while the mesh sizes are reduced by 50% in x-direction or in both directions; the results are comparable to three decimal places.
Hence, the above mesh sizes have been considered as appropriate for calculation. The coefficients and appearing in the finite-difference equations are treated as constants in any one time step. Here i-designates the grid point along the x-direction, j along the y-direction. The values of u,v and θ are known at all grid points at t=0 from the initial conditions.
The computations of u,v,θ and ϕ at time level (n+1) using the values at previous time level (n) are carried out as follows: The finite difference Eq. (19) at every internal nodal point on a particular i-level constitutes a tridiagonal system of equations. Such systems of equations are solved by using Thomas algorithm as discussed in Carnahan et al. (1969). Thus, the values of ϕ are found at every nodal point for a particular i at (n+1)th time level. Similarly, the values of θ are calculated from Eq. (18). Using the values of ϕ and θ at (n+1)th time level in Eq. (17), the values of u at (n+1)th time level are found in a similar manner. Thus, the values of ϕ, θ and u are known on a particular i-level. This process is repeated for various i-level. Thus the values of ϕ, θ,u are known, at all grid points in the rectangular region at (n+1)th time level.
In a similar manner, computations are carried out by moving along the i-direction. After computing values corresponding to each i at a time level, the values at the next time level are determined in a similar manner. Computations are repeated until the steady-state is reached. The steady state solution is assumed to have been reached, when the absolute difference between the values of u, as well as temperature θ and concentration ϕ at two consecutive time steps are less than 10−5 at all grid points.

Results and discussion
To gain a perspective of the physics of the flow regime, we have numerically evaluated the effects of Hartmann number (M), Grashoff number (Gr), radiation-conduction parameter (R), dimensionless time (t) and porosity parameter (K), on the velocity, u, temperature, θ, concentration, ϕ, shear stress function, τ. Here we consider Gr=5=>0 (cooling of the plate) i.e. free convection currents convey heat away from the plate into the boundary layer and t=0.5R=10 throughout the discussion. Also the values of the Schmidt number (Sc), as chosen to represent the presence of various species Hydrogen (Sc=0.20, hydrogen gas diffusing in electrically-conducting air), Helium (Sc=0.30), Steam (Sc=0.60) and Oxygen (Sc=0.66). The Prandtl number Pr is taken for air at 20°C (Pr=0.71), electrolytic solution (Pr=1.0) and water (Pr=7.0). To ascertain the accuracy of the numerical results, the present study is compared with the previous study. The velocity and concentration profiles are compared with the available solutions of Jaiswal and Soundalgekar [4], and Kumar and Verma [8]. It is observed that the present results are in good agreement with those of [4,8].

W SOR codziennie przyjmowani s chorzy w stanie nietrze

W SOR codziennie przyjmowani są chorzy w stanie nietrzeźwym. Ich odsetek w stosunku do ogólnej liczby chorych jest różny i według polskich badań wynosi 11–30% [25, 26]. W szpitalnym oddziale ratunkowym w Białymstoku prowadzono badania w zakresie częstości hospitalizacji chorych z powodu zatruć. Badacze wyodrębnili osoby zatrute etanolem i podkreślili, że chorzy ci często w dużym stopniu angażują personel SOR, przez co inni pacjenci przebywający w tym czasie w oddziale mogą nie otrzymać właściwej opieki [26].
Badania prowadzone w Nowej Zelandii, mające na celu zweryfikowanie postrzegania przez personel SOR poziomu obciążenia związanego z opieką nad pacjentami pod Stattic manufacturer wpływem alkoholu, udowodniły negatywny wpływ tych chorych na pracę całego zespołu oraz samopoczucie innych pacjentów. Pracownicy spotykali się z agresją ze strony pacjentów nietrzeźwych, szczególnie z atakami słownymi i znacznymi utrudnieniami w udzieleniu pomocy medycznej. Opieka nad tą grupą chorych wywoływała negatywne nastroje u pracowników SOR [27].
Rudnicka-Drożak i wsp. badali opinie pracowników SOR na temat udzielania świadczeń zdrowotnych pacjentom w stanie zatrucia alkoholem. Jak wynika z badań, osoby nietrzeźwe bardzo często zakłócają pracę personelu medycznego oraz spokój innych pacjentów, co sprawia, że udzielanie im pomocy jest dla pracowników SOR trudne. Aż 95% respondentów miało do czynienia z agresją ze strony pacjentów będących pod wpływem alkoholu – najczęściej werbalną, ale również fizyczną oraz z autoagresją [28].
W badaniach własnych wykazano, że dla ponad 60% respondentów sprawowanie opieki nad pacjentem pod wpływem alkoholu stanowi problem. Niemal 70% badanych przyznaje, że w mniejszym lub większym stopniu sprawia im trudność wykonywanie czynności zabiegowych u tych pacjentów. Z analizy danych wynika, że pacjenci będący pod wpływem alkoholu budzą wśród personelu medycznego wiele negatywnych uczuć. Najczęściej doświadczanym uczuciem była niechęć, złość i lęk, w dalszej kolejności – zniecierpliwienie i obrzydzenie. Zastanawiający jest fakt, że w opiece i w podejściu do chorego pod wpływem alkoholu występują istotne różnice w zależności od miejsca zatrudnienia badanych: w SOR czy w innych Nonsense suppresser oddziałach. Być może na taką sytuację ma wpływ sposób funkcjonowania szpitali w Polsce. Nietrzeźwy chory w pierwszej kolejności trafia do SOR, gdzie, poza diagnostyką i leczeniem, wykonywane są czynności pielęgnacyjno-higieniczne, których zazwyczaj ta grupa chorych wymaga. Skoro szybkość metabolizowania alkoholu jest uwarunkowana genetycznie i osobniczo zmienna [11], to prawdopodobnie przebyte w SOR leczenie wpływa pozytywnie na metabolizm alkoholu i chory, który trafia na dalszą hospitalizację do oddziału szpitalnego znajduje się w znacznie lepszym stanie niż w chwili przyjęcia do SOR. Pracownicy oddziałów szpitalnych powinni jednak w stosunku do tych chorych zachować wzmożoną czujność, ponieważ nagłe zaprzestanie picia alkoholu przez osoby uzależnione prowadzi do wystąpienia objawów zespołu abstynencyjnego [29]. Inni badacze potwierdzają fakt leczenia osób uzależnionych od alkoholu w oddziałach chirurgicznych [30, 31].
Z badań przeprowadzonych przez Wieczorka wynika, że „osoby uzależnione od alkoholu doświadczają stygmatyzacji nie tylko ze strony środowiska społecznego, w którym żyją, lecz również od osób zatrudnionych w systemie opieki zdrowotnej. Przywiązywanie przez personel nadmiernej wagi do niemedycznych aspektów używania alkoholu i narkotyków, postrzeganie związanych z tym problemów w kategoriach moralnych i złego zachowania, mogą pogorszyć obraz osób z zaburzeniami psychicznymi spowodowanymi przez nadużywanie substancji psychoaktywnych” [12]. Ponadto, według Bujalskiego, dyskryminacja staje się najbardziej wyraźna w sytuacjach, gdy personel poniża pacjenta lub odmawia mu udzielenia pomocy [17].

br Conclusion La chirurgie conservatrice pour cancer du rein

La chirurgie conservatrice pour cancer du rein hcv virus de bons résultats tant sur le plan carcinologique que fonctionnel. Malheureusement, elle n’a pas encore la place qu’elle mérite actuellement. La crainte de la morbidité et l’essor de la néphrectomie totale élargie laparoscopique constituent un frein à son développement. La limite en taille communément admise de 7cm mérite d’être discutée. L’évolution naturelle se fait vers la chirurgie conservatrice quelque soit la taille de la tumeur et quelque soit le rein controlatéral à condition qu’elle soit techniquement réalisable.

Les traumatismes sont les principales causes de mortalité chez le sujet jeune entre 1 et 44ans. En urologie, le rein est l’organe le plus fréquemment atteint [1]. Le scanner spiralé avec injection de produit de contraste est le meilleur examen pour confirmer le diagnostic et apprécier l’étendue des lésions [2]. La classification utilisée pour décrire les traumatismes du rein est la classification de l’ASST (comité américain de chirurgie traumatologique) [3]. Le traitement des traumatismes fermés rénaux majeurs reste un sujet de débat: opérer ou surveiller? A travers une étude rétrospective concernant 44 cas de traumatismes rénaux fermés et à travers une revue de la littérature, nous avons étudié les aspects diagnostiques et thérapeutiques récents des traumatismes fermés du rein.

Patients et Methodes

Dans notre série, le sexe masculin était prédominant il s’agissait de 40 hommes (91%) et 4 femmes (9%). L’âge moyen était de 26ans avec des extrêmes de 15 et 70ans. Le côté gauche était le plus fréquemment atteint (57%). Les étiologies des traumatismes étaient les accidents de la voie publique (21 cas), des chutes (13 cas), des agressions (7cas), des traumatismes anodins (4 cas), et des accidents du sport (3 cas). Vingt-un patients étaient polytraumatisés, avec des lésions associées viscérales (11 cas), et osseuses (13 cas). Cinque patients ont eu une uropathie malformative ou acquise révélée par le traumatisme rénal (soit une fréquence de 11,3%). Sur le plan clinique, l’hématurie macroscopique était présente dans 33 cas. 5 patients ont été admis en état de choc hémorragique; l’un est rapidement corrigé par le remplissage vasculaire; Les quatre autres malades ont été opérés en urgence, deux par néphrectomie totale avec une hépatectomie partielle chez un patient et deux par néphrorraphie avec une splénéctomie d’hémostase (tableau I).
En effet, le traitement chirurgical a cis-acting protein été nécessaire dans 11 cas (6 Grade III, 3 Grade IV, et 2 Grade V), avec une néphrorraphie (en urgence différée), neuf néphrectomies totales (3 en urgence immédiate et 6 en urgences différées) dont une était totale et élargie devant un traumatisme sur un adénocarcinome rénal, et chez un seul malade l’attitude était l’abstention, après une laparotomie en urgence devant un tableau de péritonite urineuse suite à un traumatisme Grade III sur un rein unique (tableau II).

Les traumatismes de l’ensemble de l’appareil urogénital représentent 1% à 5% de la traumatologie; et les traumatismes du rein sont les plus fréquents des lésions traumatiques de cet appareil: 64% [1]. 80 à 90% de ces traumatismes sont dus à des accidents de la voie publique, des chutes et des accidents de sport [2,3]. L’homme est le plus fréquemment atteint [1]. Le traumatisme rénal peut survenir à tout âge avec une prédominance chez le sujet jeune essentiellement entre 20 et 40ans [1].L’hématurie est le maitre symptôme, elle est macroscopique dans 66.6 à 99% [1,4]. Sa détection doit se faire sur le premier jet d’urine, car celle-ci peut disparaître au cours de la seconde et troisième miction [5]. Les lésions associées sont assez fréquentes et peuvent être viscérales, osseuses ou crânio-cérébrales [6]. Le bilan lésionnel initial recommandé actuellement est le scanner spiralé qui doit être réalisé en urgence devant:

In Sheldon et al have proposed a system for

In 1984, Sheldon et al. [11] have proposed a system for clinical staging of urachal adenocarcinoma. In this system, early stage urachal cancers are localized to the urachal mucosa, whereas late stage disease involves local structures, like the bladder, abdominal wall or peritoneum, and metastases to regional lymph nodes or distant sites (Table 1). The Mayo clinic has suggested recently a more simplified system (Table 2) [10]. But none of them are validated.
There is currently no standard adjuvant or metastatic chemotherapy protocol for the treatment of urachal adenocarcinoma. The choice of protocols has been based largely on case reports and single institutional experiences. The results of the phase II trial of gemcitabine+cisplatin+5-FU might further define a treatment standard for this disease [4].
Recent case reports show the benefit of combined chemotherapy in isolated cases of urachal cancers, most of them adenocarcinomas: the association of 5-FU, cisplatin or oxaliplatin, irinotecan and bevacizumab in different combinations demonstrated usually a partial and limited response [15–18].
Siefker-Radtke et al. [7] have reported a 46-month overall survival from diagnosis of 42 patients (including 7 with metastasis, and 35 with resectable disease). Forty percent of them survive for 5 years. Of the resected cases, 46% remain disease-free with a median follow-up of 31 months. Long-term survival was associated with negative surgical margins (P=0.004) and absence of nodal involvement (P=0.01).

Conflict of interest

Case presentation
A 78-year-old female was referred to Tygerberg Hospital with a 2–3 year complaint of total urinary incontinence. She did not have any other specific urologic complaints. She had a history of two vaginal births but no prior pelvic surgery. Physical exam was essentially unremarkable except for a firm mass palpated along the anterior vagina consistent with a stone. She could not tolerate a speculum vaginal exam because of the severe pain. Urine culture grew Klebsiella, for which appropriate shk manufacturer were started. Further laboratory studies were normal. A KUB X-ray demonstrated an irregularly shaped calcification within the pelvis (Fig. 1). Ultrasonography showed the calcification to involve the urinary bladder. Our initial differential diagnosis included a urethral diverticulum that had formed a stone and eroded into the vagina, as well as an underlying urethral or gynecologic malignancy. The patient was then scheduled for a diagnostic cystoscopy with possible vesicolithotomy given the relatively large size of the stone.
Examination was performed under anesthesia and the vaginal mass was confirmed to be an irregularly shaped stone with jagged edges. Cystoscopy showed a smooth bladder stone that appeared to be continuous with the vaginal stone (Fig. 2). We were able to successfully perform cystolithalopaxy by crushing the bladder component of the stone using an Olympus® Stone Punch (Olympus® Corporation, Tokyo, Japan), and the vaginal component removed manually. A foreign body (aerosol cap) was identified in the vagina as the underlying cause (Fig. 3). The aerosol cap had eroded through the anterior vaginal wall resulting in a 2–3cm vesicovaginal fistula. The rectum was not involved. A biopsy of the fistulous tract demonstrated granulation tissue with no evidence of malignancy. Upon further interview, the patient did not acknowledge nor gave any clear history to explain the presence of the retained foreign body.

Retained foreign bodies causing vesicovaginal fistula has been reported in the literature, specifically aerosol bottle caps [1–3]. Contraception and masturbation have been described as reasons for placing an aerosol cap within the vagina [1], but sexual abuse must also be considered as a possibility in these cases. It is also conceivable that elderly patients may use such an object as a makeshift pessary for pelvic organ prolapse.
Evans et al. reported on a vesicovaginal fistula that formed several weeks after the uneventful removal of a bottle cap from a 16-year-old woman. Although there was no fistula identified on initial evaluation she presented weeks later with intermittent leakage, urinary urgency and occasional urge incontinence [2]. It is, therefore, important to carefully assess for fistulae during the initial presentation as well as have close follow up with the patient. Reports of rectovaginal fistulae have also been published related to neglected pessary devices [4].