Contemporary evaluation and management of the female urethral diverticulum

We are in agreement with Davis and Telinde, who state, "The most important single diagnostic instrument for the discovery of suburethral diverticula is the high index of suspicion" [25]. The key to successful treatment of a female diverticulum is not only in the surgical management but also in the identification and evaluation of patients who present with a myriad of symptoms. It is our responsibility to include urethral diverticula in the differential diagnoses before the labels of interstitial cystitis, urethral syndrome, or urgency frequency syndrome are misplaced. The diagnosis may be elusive and the pathology difficult to identify on physical examination. However, if the index of suspicion is high and the proper radiologic imaging studies are gathered, then the correct diagnosis will often be made. The evaluation of the female urethral diverticulum has evolved greatly over the past several years. However, once appropriate diagnosis is made, the management scheme is fairly straightforward. Strict adherence to principles of surgical reconstruction allows one to eradicate the diverticulum while simultaneously preventing complications and recurrences.     

Intraobserver reproducibility of a two-dimensional mapping of the optic nerve head perfusion

PURPOSE: To evaluate the intraobserver reproducibility of a software designed to assess retinal blood flow with the Heidelberg Retina Flowmeter (HRF). METHODS: Ten subjects were consecutively recruited, and one eye of each patient was randomly selected for study. Blood flow measurements were analyzed by using an automatic full field perfusion image analysis (AFFPIA) program, which calculates the Doppler frequency shift and hemodynamic variables (flow, volume, and velocity) for each pixel. The resulting perfusion image is processed with respect to underexposed and overexposed pixels, saccades, and retinal vessel tree. Intraobserver reproducibility was calculated for the AFFPIA program. All the optic nerve heads were horizontally divided into three sections (superior, central, and inferior). The retinal blood flow was calculated in the superior and inferior section, and each section was further divided into three areas (temporal, nasal, and rim). The blood flow was evaluated for each area. RESULTS: When the same observer analyzed the same image five times (intraobserver intraimage reproducibility), the AFFPIA coefficient of variation ranged from 0.5% to 5% in the temporal area, from 0.1% to 5.3% in the nasal area, and from 0.5 to 28% in the rim area.When the same observer analyzed three different images of the same section once (intraobserver interimage reproducibility), the AFFPIA coefficient of variation of flow measurements ranged from 1% to 7.3% in the temporal area, from 1.5% to 10% in the nasal area, and from 2 to 30% in the rim area. CONCLUSION: Retinal blood flow measured by HRF and analyzed by AFFPIA had good intraobserver reproducibility. The reproducibility was significantly better in the temporal and nasal areas than in the rim area.     

Heterotrimeric GTP-binding proteins in the lacrimal acinar cell endomembrane system

Secretagogues accelerate traffic in the lysosomal and basal-lateral pathways, as well as in the regulated apical secretory pathway, of lacrimal acinar cells. It has been proposed that alterations of protein segregation in compartments where these traffic pathways intersect may influence autoimmune responses. Heterotrimeric GTP-binding proteins couple secretagogue receptor ligand binding to activation of intracellular signaling cascades, but they are also suggested to participate in endomembrane traffic phenomena. Distributions of G(o), G(i3), G(q), G(11), and two G(s)isoforms were mapped in reconstituted lacrimal acini by confocal immunofluorescence microscopy and in lysates of the reconstituted acini by analytical subcellular fractionation. All G proteins examined were detected at low levels in isolated compartments (blm(i,j)) believed to represent the basal-lateral plasma membrane. G(i3), G(11), and the G(s)isoforms were concentrated in a series of isolated compartments believed to be related to domains of a basal-lateral endosome with sorting and recycling functions (ble-s/r(i,j,k)), a distinct endosomal compartment with basal-lateral membrane-like composition (e-blml), and domains of the trans-Golgi network believed to be involved in traffic to and from the basal-lateral membrane (tgn-blmr). G(o)and G(q)were concentrated in compartments believed to represent a mixture of immature and mature secretory vesicle membranes (isvm and svm) and domains of the trans-Golgi network compartment believed to mediate traffic to secretory vesicles (tgn-svr) and to pre-lysosomes (tgn-lr). Confocal fluorescence microscopy confirmed the presence of both basal-lateral membrane and intracellular pools of the G proteins. Stimulation with 10 microM carbachol for 20min caused a component of the G(o)to redistribute away from the isvm+svm; components of the G(i3), G(q), and G(s)to redistribute away from the tgn-svr+tgn-lr; and a component of the G(i3)to redistribute away from the ble-blml+tgn-blmr. Thus, these proteins may participate in endomembrane traffic steps activated by cholinergic stimulation in addition to playing their classical roles in plasma membrane signal transduction.     

Consultant development. Role rehearsal

Most newly appointed consultants have had no training in management. Consultants who have been in post for several years may need extra management development to become clinical directors, medical directors or chief executives. A training scheme initiated in the West Midlands appears to have been well received and is being extended.