61 research outputs found
Long-term results after acute therapy of obstructive pyelonephritis
INTRODUCTION To evaluate therapeutic results till 5 years after therapy of obstructive pyelonephritis (OPN) emphasizing regular follow-up. MATERIAL AND METHODS During 5 years, 57 patients with OPN were treated. The patients' charts were reviewed retrospectively for clinical data. These were completed by a questionnaire. RESULTS In the group of 57 patients (average age 56 years), about two third were women. Urolithiasis (65%) and tumors (21%) were the main causes of obstruction; fever (91%) and loin pain (86%) the main symptoms. Three fourth of the patients showed renal insufficiency and nearly 50% anemia. E. coli and Proteus spp. were the dominating organisms. Sonography detected obstruction in 93% cases. In one third of cases, CT scan was added; 81% percutaneous nephrostomy and 19% ureteral stenting were the initial methods of urinary drainage. During therapy, 23% nephrectomies (19% complete, 4% partial) were performed. Long-term follow-up showed 11% recurrent OPN and 33% recurrent UTI. CONCLUSIONS After diagnosis of OPN, primary nephrostomy or ureteral stenting and antibiotic therapy are the first measures. If recurrent urinary tract infections or OPN occur, long-term follow-up and low-dose antibiotic prophylaxis may be discussed
Similarities and differences in the autonomic control of airway and urinary bladder smooth muscle
The airways and the urinary bladder are both hollow organs serving very different functions, i.e. air flow and urine storage, respectively. While the autonomic nervous system seems to play only a minor if any role in the physiological regulation of airway tone during normal breathing, it is important in the physiological regulation of bladder smooth muscle contraction and relaxation. While both tissues share a greater expression of M2 than of M3 muscarinic receptors, smooth muscle contraction in both is largely mediated by the smaller M3 population apparently involving phospholipase C activation to only a minor if any extent. While smooth muscle in both tissues can be relaxed by β-adrenoceptor stimulation, this primarily involves β2-adrenoceptors in human airways and β3-adrenoceptors in human bladder. Despite activation of adenylyl cyclase by either subtype, cyclic adenosine monophosphate plays only a minor role in bladder relaxation by β-agonists; an important but not exclusive function is known in airway relaxation. While airway β2-adrenoceptors are sensitive to agonist-induced desensitization, β3-adrenoceptors are generally considered to exhibit much less if any sensitivity to desensitization. Gene polymorphisms exist in the genes of both β2- and β3-adrenoceptors. Despite being not fully conclusive, the available data suggest some role of β2-adrenoceptor polymorphisms in airway function and its treatment by receptor agonists, whereas the available data on β3-adrenoceptor polymorphisms and bladder function are too limited to allow robust interpretation. We conclude that the distinct functions of airways and urinary bladder are reflected in a differential regulation by the autonomic nervous system. Studying these differences may be informative for a better understanding of each tissue
Dislocazione a sinistra, tema sospeso und dislocazione a destra - Gebrauch und Funktionen der Herausstellungsstrukturen im Italienischen
Die Arbeit fasst zunächst in einem theoretischen Teil den Stand der Forschung zu Linksversetzung, Freiem Thema und Rechtsversetzung im Italienischen zusammen. Nach einer deskriptiven Analyse der Strukturen der drei Konstruktionstypen folgt eine empirische ĂberprĂźfung der pragmatischen Funktionen anhand verschiedener Korpora. Ferner wird gezeigt, inwieweit Kombinierbarkeit der drei Herausstellungsstrukturen mĂśglich ist. Eventuelle Ăźbereinzelsprachliche Charakteristika der Herausstellungsstrukturen werden anhand eines Vergleichs mit dem Englischen (left-dislocation) ergrĂźndet. Der Gebrauch der Konstruktionen wird des weiteren unter Hinzuziehung von Datenerhebungen aus der italienischen Alltagssprache auf diasystem-bedingte (insbesondere diachronische und diamesische) Einflussfaktoren hin untersucht. Eine Bewertung der Behandlung des Themenkomplexes in den einschlägigen Grammatiken des Italienischen bildet den abschlieĂenden Teil der Arbeit
Ethics of disaster medicine : a critical analysis of subject-specific dilemmas: resource allocation, instrumentalization and divided loyalty
Krisemedizin gewinnt im Rahmen sich wandelnder Kriegsformen, terroristischer Ăbergriffe und der MĂśglichkeit des Einsatzes von Massenvernichtungswaffen erheblich an Bedeutung. Zivile Katastrophenmedizin und militärische Einsatzmedizin stehen daher vor deutlich hĂśheren Herausforderungen. Die vorliegende Arbeit versucht die Konzeption einer krisenmedizinischen Ethik unter BerĂźcksichtigung dreier bereichsspezifischer Problemfelder: die Allokation lebenswichtiger, jedoch begrenzt verfĂźgbarer Ressourcen, die Instrumentalisierung einer Medizin im Dienste des Militärs sowie die Doppelloyalität des Sanitätsoffiziers. Unter Beachtung der Werte und WĂźnsche aller Beteiligten werden Zielsetzungen formuliert. Sie stellen die Grundlage eines dreistufig hierarchischen Prinzipienkonstrukts aus allgemeinen ärztlichen und humanitären Prinzipien, Allokations- i.e. Organisationsprinzipien und Behandlungsprinzipien dar. Die entwickelte Systematik fasst die in der Literatur meist unĂźbersichtlich dargestellten Handlungsgrundsätze zusammen und ergänzt diese bisweilen. Allokationsprinzipien werden einer Differenzierung unterzogen und gliedern sich in Prinzipien, welche ausschlieĂlich den Zugang zum Zuteilungsverfahren festlegen, und solche, die die Verteilung der Ressource regeln. Letztere basieren auf Kriterien, wobei hier allein dem Alter neben der Ăberlebenswahrscheinlichkeit ein Stellenwert eingeräumt werden kann, während Beurteilungen von Patienten basierend auf deren âsocial worthâ strikt abzulehnen sind. Die Ressourcenzuteilung im Rahmen von Krisensituationen muss unter BerĂźcksichtigung dreier Handlungsgrundsätze erfolgen: Gerechtigkeits- und Effizienzprinzipien zusammen mit einem neu formulierten Praktikabilitätsprinzips. Ein zur Regel oder Norm zusammenzufassender Goldstandard ist dabei nicht zu erreichen. Vielmehr muss eine KompromisslĂśsung auf der Basis einer situativen Prinzipiengewichtung angestrebt werden, weshalb oft ein nicht intendiertes, jedoch âzu akzeptierendes Unrechtâ in Kauf genommen werden muss. Die Beurteilung einer Krisenmedizin wird daher nur im Sinne eines intentionalistischen Konsequenzialismus erfolgen kĂśnnen. Triage versucht einen Ausweg aus diesem Gewichtungsdilemma. Sie kategorisiert Patienten in vier Schweregrade, wobei einer Gruppe die Prognose âHoffnungslosigkeitâ zugeschrieben wird. Hierdurch werden zwei Bereiche unterschiedlicher Prinzipiengewichtung definiert. Gerechtigkeitsprinzipien wird der Vorzug bei Patienten mit hĂśherer Ăberlebenswahrscheinlichkeit eingeräumt. Bei Patienten mit niederer Ăberlebenswahrscheinlichkeit dominieren effizienzorientierte Prinzipien. Krisenmedizin unter dem Diktat des Militärs ist darĂźber hinaus einer weiteren Problematik ausgesetzt: Die Konkurrenz medizinischer und militärischer Ziele. Eine fĂźr das Militär instrumentalisierte Medizin verliert ihrer Eigenständigkeit, indem sie sich fremden Imperativen unterordnen muss. Doch weder absolute Eigenständigkeit der Medizin im Einsatz noch vollständige Instrumentalisierung im Sinne des Militärs scheinen zu erstrebenswerten Vorteilen zu fĂźhren. Der Sanitätsoffizier personifiziert hierbei den Konflikt zweier Systeme und Ethiken. Ihm kommt die Aufgabe einer temporär unterschiedlichen Gewichtung medizinischer und militärischer Zielsetzungen zu, die auf institutionaler Ebene nicht geleistet werden kann. Die Dominanz militärischer Interessen fĂźhrt hierbei zu einer Verschiebung weg von der individualethischen hin zu einer eher sozialethischen Position. Gerechtigkeitsprinzipien weichen zunehmend effizienzorientierten Prinzipien, was sich in einem vom Zivilen differenten Gesundheits- bzw. Krankheitsbegriff widerspiegelt. Zusammenfassend ist fĂźr Krisensituationen eine umfassende Medizinethik nicht zu leisten. Eine Ethik wird nur Grenzen und MĂśglichkeiten aufzeigen kĂśnnen, ohne jedoch den Handlungsspielraum fĂźr Einzelfallentscheidungen exakt vorgeben zu kĂśnnen. Ziele und Prinzipien konkurrieren bisweilen, so dass vom einzelnen eine Gewichtung vorgenommen werden muss. Gerechtigkeit, NĂźtzlichkeit und Praktikabilität scheinen dabei gleichermaĂen verwirklicht werden zu wollen, was stets KompromisslĂśsungen erfordert. Die Fähigkeit, sich in dieser Grauzone ethischen Handelns zurechtfinden zu kĂśnnen, erfordert neben medizinisch-fachlicher Expertise eine tugendhafte innere Haltung sowie eine moralisch-ethische Kompetenz und MĂźndigkeit. Dieser Kompetenz mĂśchte ich grĂśĂtes Gewicht beimessen. Sie ist die Fähigkeit, ethischen Dilemmata mit situativ unterschiedlicher Kompromissbereitschaft entgegnen zu kĂśnnen.The medical response to public emergencies is gaining considerable significance as a result of ongoing changes in modes of warfare, terrorist attacks and the possible use of weapons of mass destruction. Conspicuously greater challenges are therefore posed by disaster response in the civil medical field and in operational military medicine. The present study attempts to provide an ethical concept to guide the medical response to public emergencies, taking account of three problematic aspects that are specific to this subject: the allocation of vitally important yet limited resources, the instrumentalization of medical expertise in support of the military, and the divided loyalty of the military medical officer. Objectives taking account of the values and wishes of all parties involved have been established. They provide the basis for a three-stage hierarchy of principles comprising general medical and humanitarian principles, allocational (i.e. organizational) principles, and principles relating to treatment. The taxonomy that has been developed brings together and supplements the principles of action which are represented in the literature mostly without structure. Allocation principles are differentiated and subdivided into those which solely specify the approach to the allocation process and those which govern the distribution of resources. The principles in the latter category are based upon criteria. In this context, only age and probability of survival can be accorded any importance as criteria, whereas the assessment of patients on the basis of their âsocial worthâ has to be strongly rejected. Resource allocation in crisis situations has to be performed with three principles in mind: fairness, efficiency and a newly established principle of practicability. It is not feasible to define a gold standard that can be summarized to become an established rule or norm. Instead of this, it is essential to aim for a compromise solution on the basis of a situationally appropriate evaluation based upon principles, the result of which is often an unintended injustice that nevertheless has to be accepted. The evaluation of a medical response to a public emergency will therefore only be executable on the basis of intentionalistic consequentialism. Triage is an attempt to provide a way out of this evaluative dilemma by categorizing patients into four groups covering various degrees of severity, with the prognosis for one group being assessed as âhopelessâ. Hence, two areas with differently weighted principles are defined. In accordance with the principle of fairness, priority is granted to patients with a higher probability of survival, whereas efficiency-based principles are the dominant factor with regard to patients with a lower probability of survival. Furthermore, medical response to emergencies under military fiat involves another complex problem: the rivalry between medical and military objectives. Medical services instrumentalized for the military lose their independence because they have to accept subordination to othersâ imperatives. Yet neither absolute independence of military operational medicine nor complete instrumentalization to meet the demands of the military seems to produce desirable advantages. In this respect the military medical officer personifies the conflict between two systems with differing ethics. He is given responsibility for the task â which cannot be performed at institutional level â of weighing up the temporarily different demands stemming from medical and military objectives. In this situation the dominance of military interests leads to a shift away from an individual ethical attitude towards a position tending to social ethics. Principles of fairness increasingly have to make way for efficiency-based principles, and this is reflected in concepts of health and sickness that differ from those prevailing in the civil sector. In short, a comprehensive system of medical ethics for public emergencies is unachievable. Ethics can be used in identifying limitations and options, but will not be able to specify in exact terms the freedom of action with regard to decisions on individual cases. Different objectives and principles may occasionally compete with each other, so the individual decision-maker will have to evaluate the situation. It appears desirable to achieve fairness, efficiency and practicability in equal degree, and this will always necessitate compromise solutions. The ability to deal aptly with this grey area of ethical action requires not only professional medical expertise but also a virtuous inner attitude and moral-ethical competence and maturity. I wish to attribute the greatest importance to this competence: it is the ability to face ethical dilemmas with a situationally appropriate willingness to engage in compromise
Expression of nicotinic acetylcholine receptor subunit mRNA in mouse bladder afferent neurons
Nicotinic acetylcholine receptors (nAChR) influence bladder afferent activity and reflex sensitivity, and have been suggested as potential targets for treating detrusor overactivities. Mechanisms may include indirect effects, e.g. involving the urothelium, and direct action on nAChR expressed by afferent neurons. Here we determined the nAChR repertoire of bladder afferent neurons by retrograde neuronal tracing and laser-assisted microdissection/RT-PCR, and quantified retrogradely labelled nAChRÎą3-subunit expressing neurons by immunohistochemistry in nAChR Îą3β4Îą5 cluster eGFP reporter mice. Bladder afferents distinctly expressed mRNAs encoding for nAChR-subunits Îą3, Îą6, Îą7, β2-4, and weakly Îą4. Based upon known combinatorial patterns of subunits, this predicts expression of at least three basically different subunits of nAChR - Îą3â, Îą6â and Îą7â - and of additional combinations with β-subunits and Îą5. Bladder afferents were of all sizes, and their majority (69%; n=1367) were eGFP-nAChRÎą3 positive. Immunofluorescence revealed immunoreactivities to neurofilament 68, transient receptor potential cation channel vanilloid 1, substance P and calcitonin gene-related peptide in eGFP-nAChRÎą3-positive and -negative neurons. For each antigen, all possible combinations of colocalisation with eGFP-nAChRÎą3 were observed, with eGFP-nAChRÎą3-positive bladder neurons without additional immunoreactivity being most numerous, followed by triple-labelled neurons. In conclusion, more than one population of bladder afferent neurons expresses nAChR, indicating that peripheral nicotinic initiation and modulation of bladder reflexes might result, in addition to indirect effects, from direct activation of sensory terminals. The expression of multiple nAChR subunits offers the potential of selectively addressing functional aspects and/or sensory neuron subpopulations
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