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The first step in developing a synthetic peptide vaccine for plague is to treatment bacterial vaginosis buy generic benazepril from india identify the relevant antigen(s) determine their amino acid sequence symptoms 10 dpo order benazepril online pills, and identify protective B and T cell epitopes treatment hepatitis c discount benazepril 10mg on line. The immunogenicity of the B cell (B1 treatment kidney cancer order 10mg benazepril, B2, and B3) and T cell (T1, T2) peptides was studied in mice using alhydrogel and liposomes as delivery vehicles. Later, several B and T cell epitopes of V antigen were identified by direct binding, competitive, and T cell proliferation approaches. V antigen peptides a, g and j were found to be pure B cell epitopes and peptides d and k pure T cell epitopes, whereas other peptides b, f and i showed both B and T cell properties (Khan and Rao, 2008). Furthermore, mice immunized intranasally with B-T conjugates of V antigen peptides entrapped in microspheres resulted in high titers of serum and mucosal IgG and IgA upto 120 day postimmunization. Interestingly, some of the conjugates showed enhanced protection in mice challenged with live bacteria (Uppada and Rao, 2009). Future perspectives the development of a fully protective vaccine against plague remains a challenge. None of the formulations of F1 and V based vaccines were fully protective against experimental infections. The ideal vaccine would stimulate robust antibody and cell mediated immune response with respect to serum IgG, IgG sub classes and mucosal IgA along with Th1/ Th2 /Th17 cytokines correlation. Standardized procedures will facilitate human clinical trials to determine vaccine formulations, dosages and schedules that best prime protective responses. Furthermore, using different ways of immunization with novel delivery vehicles and adjuvants could enhance the immune response and efficacy of different formulations. This preparation gave a better immunogenicity profile than that of single epitope based immunogens. A better understanding of virulence mechanisms, host pathogen interactions that operate within the body and especially the lungs during infection, could provide some new alternative targets for vaccines and therapeutics. The focus should be on the pneumonic form of disease rather than the bubonic and septicemic forms. Synthetic microbial 96 Bioterrorism products that activate the Th1 and Th17 pathways are also beneficial to host immunity. However, given present concerns for bioterrorism, which may involve the release of aerosolized Y. Mutational analysis of the Yersinia enterocolitica virC operon: characterization of yscE, F, G, I, J, K required for Yop secretion and yscH encoding YopR. Higher accumulation of F1-V fusion recombinant protein in plants after induction of protein body formation. CpG oligodeoxynucleotides augment the murine immune response to the Yersinia pestis F1-V vaccine in bubonic and pneumonic models of plague. Shortand longterm efficacy of single-dose subunit vaccines against Yersinia pestis in mice. Recombinant V antigen protects mice against pneumonic and bubonic plague caused by F1-capsule-positive and negative strains of Yersinia pestis. YopH of Yersinia pseudotuberculosis interrupts early phosphotyrosine signaling associated with phagocytosis. Protective efficacy of recombinant Yersinia outer proteins against bubonic plague caused by encapsulated and nonencapsulated Yersinia pestis. Plague meningitis?a retrospective analysis of cases reported in the United States, 1970 1979. Essential virulence determinants of different Yersinia species are carried on a common plasmid. Development of a vaccinia virus based reservoirtargeted vaccine against Yersinia pestis. Contemporary views on the interrelationships between fleas and the pathogens of human and animal diseases. Bioterrorism Overview, Centers for Disease Control and Prevention, 2008-02-12, retrieved 2009-05-22. Role of YopP in suppression of tumor necrosis factor alpha release by macrophages during Yersinia infection. Assessment of a fluoroquinolone, three b-lactams, two aminoglycosides, and a cycline in treatment of murine Yersinia pestis infection. Interleukin-10 and inhibition of innate immunity to yersiniae: roles of Yops and LcrV (V antigen). The role of multiplication of Pasteurella pestis in mononuclear phagocytes in the pathogenesis of flea-borne plague. Specific effect of temperature upon transmission of the plague bacillus by the oriental rat flea, Xenopsylla cheopis. Pathology of experimental pneumonic plague produced by fraction 1-positive and fraction 1-negative Yersinia pestis in African green monkeys (Cercopithecus aethiops). Plant-derived recombinant F1, V, and F1-V fusion antigens of Yersinia pestis activate human cells of the innate and adaptive immune system. Cat-transmitted fatal pneumonic plague in a person who traveled from Colorado to Arizona. Study of three immunizing preparations in protecting primates against pneumonic plague. Three Yersinia pestis adhesins facilitate Yop delivery to eukaryotic cells and contribute to plague virulence. Relationship between virulence and immunity as revealed in recent studies of the F1 capsule of Yersinia pestis. Human plague in the United States: a review of cases from 1988?1992 with comments on the likelihood of increased plague activity. Results of 30 years of work on the Pasteurella pestis Ev (Girard and Robic) strain. Role of YopH in the suppression of tyrosine phosphorylation and respiratory burst activity in murine macrophages infected with Yersinia enterocolitica. Protection against experimental bubonic and pneumonic plague by a recombinant capsular F1-V antigen fusion protein vaccine. New method for plague surveillance using polymerase chain reaction to detect Yersinia pestis in fleas. Polymerization of a single protein of the pathogen Yersinia enterocolitica into needles punctures eukaryotic cells. The pH 6 antigen is an antiphagocytic factor produced by Yersinia pestis independent of Yersinia outer proteins and capsule antigen. Protective Immunity in Mice Achieved with Dry Powder Formulation and Alternative Delivery of Plague F1-V Vaccine. YopT, a new Yersinia Yop effector protein, affects the cytoskeleton of host cells. Relationship between loss of pigmentation and deletion of the chromosomal ironregulated irp2 gene in Yersinia pestis: evidence for separate but related events. Vaccination of Mice with a Yop Translocon Complex Elicits Antibodies That Are Protective against Infection with F1-Yersinia pestis. A study of the correlation between virulence and relative phagocytosis resistance of some strains of Pasteurella pestis. Protection against pneumonic plague following oral immunization with a non-replicating vaccine. Protection conferred by a fully recombinant sub-unit vaccine against Yersinia pestis in male and female mice of four inbred strains. Effect of differences in ambient temperature upon the fate of Pasteurella pestis in Xenopsylla cheopis. Modification of the structure and activity of lipid A in Yersinia pestis lipopolysaccharide by growth temperature. Identifying B and T cell epitopes and studying humoral, mucosal and cellular immune responses of peptides derived from V antigen of Yersinia pestis. Progression of primary pneumonic plague: a mouse model of infection, pathology, and bacterial transcriptional activity. Active immunization with recombinant V antigen from Yersinia pestis protects mice against plague.

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Control of the brining treatment 2 go order benazepril on line, pickling treatment dynamics quality benazepril 10 mg, In some pasteurized surimi-based or formulation steps is treatment 02 academy purchase benazepril with amex, therefore medicine descriptions discount benazepril 10mg amex, critical to products, salt, in combination with a milder ensure that there are suffcient barriers in the pasteurization process, in the fnished product fnished product to prevent the growth and container works to prevent growth and toxin toxin formation of C. These control procedures properly pasteurized surimi-based product are covered in this chapter. This pickling loads to single species and to fsh process may not be suitable for other types of portions of approximately uniform size. In pickled fsh, salted fsh, caviar, and similar botulinum type A and proteolytic types B products that have not been preserved and F. Because these products may type E and non-proteolytic types B and appear to the retailer, consumer, or end user F during fnished product storage and to be intended to be refrigerated, rather than distribution is refrigeration. Control procedures to ensure that product A suitable protocol for the performance of is properly labeled with keep frozen such studies is contained in a 1992 publication instructions are covered in this chapter. Examples of shelf-stable, reduced oxygen packaged fshery products are dried fsh, the following guidance will assist you in acidifed fsh, canned fsh, and salted fsh. Adding suffcient salt to produce Understand the potential hazard, under the a water phase salt level. Note: A heat treatment, addition of chemical additives, or other treatment may be necessary to inhibit or eliminate spoilage organisms. Is there an acidifcation step (equilibrium pH In these cases, you should also identify of 4. Control of hot-fll steps, or a retorting step (commercial refrigeration is covered in this chapter for sterility) in the process? Other processing steps process in the fnished product container where you have identifed C. Guidance provided in Control be provided for time and temperature Strategy Example 4 Pickling and Salting exposure during fnished product may be useful in developing controls at storage and distribution of the following this step. If there is no acidifcation step and the smoking step should be identifed as (equilibrium pH of 4. The smoking step for step, pasteurization step, cooking and hot-smoked fsh should be suffcient to damage hot-flling, or retorting (commercial the spores and make them more susceptible to sterility) step in the process, then decide inhibition by salt. The smoking step for coldwhich of the following categories best smoked fsh should not be so severe that it kills describes your product and refer to the the natural spoilage bacteria. These bacteria guidance below: are necessary so that the product will spoil before toxin production occurs. Is the water phase salt level and, when permitted, Refrigerated (not frozen) fnished product the nitrite level, important to the safety of the product? Nitrite, when permitted, present in most smoked or smoke-favored allows a lower level of salt to be used. Bacillus cereus can grow and form and nitrite are the principal inhibitors to toxin at water phase salt concentrations as C. The water phase salt level needed referred to in this chapter as Control Strategy to inhibit toxin formation is partially achieved Example 1 Smoking (1d Refrigerated during brining or dry salting and is partially Finished Product Storage). In some cases, salted, smoked, or smokefavored fsh are received as ingredients this control approach is a control strategy for assembly into another product, such referred to in this chapter as Control Strategy as a salmon pate. In other cases, they are Example 1 Smoking (1a Brining, Dry received simply for storage and further Salting, and Drying). Is the temperature of the heating or smoking case, the refrigerated (not frozen) storage step process important to the safety of the product? As previously noted, maintenance of this control approach is a control strategy temperatures below 38?F (3. Is the storage temperature important to the safety be an appropriate means of overcoming these of the product? These products contain no barriers (other this control approach is a control strategy than refrigeration) to toxin formation by C. Is the storage temperature important to the safety this control approach is a control strategy of the product? These products contain no barriers (other In some cases, these products are received as than freezing) to toxin formation by C. Control the following guidance provides four control should be exercised over the relevant step. You this control approach is a control strategy may select a control strategy that is different from referred to in this chapter as Control Strategy those which are suggested, provided it complies Example 4 Pickling and Salting (4a with the requirements of the applicable food Brining, Pickling, Salting, and Formulation). Is the storage temperature important to the safety used in combination to result in an effective of the product? Unless pickling, brining, or formulation results the following are examples of control strategies in a water phase salt level of at least 20% included in this chapter: (note that this value is based on the maximum salt concentration for growth of S. Brining, dry salting, and drying; products are received as ingredients for assembly into another product. Receipt of products by secondary Control is the same as that provided under processor. The critical factors are those temperature-recording device that are necessary to ensure that the fnished. The critical Monitor the drying time and the input/ factors may include: brine strength; brine to output air temperature (as specifed fsh ratio; brining time; brining temperature; by the study) using a continuous thickness, texture, fat content, quality, and temperature-recording device. These fnished product and conduct water phase may include: brine strength; brine to fsh salt analysis and, when appropriate, nitrite ratio; brining time; brining temperature; analysis. Take the following corrective action to a product Establish a Recordkeeping System. It (212?F (100?C)) if the device will be used should be designed to consistently at or near the boiling point. Note that achieve a water phase salt level of the temperature should be adjusted to 3. Such Doing a combination of the above if knowledge can be obtained by education the device will be used at or near room or experience, or both. In other instances, existing temperature range at which it will be literature, which establishes minimum used; processes or adequacy of equipment, is available. Continuous monitoring by the device itself, variations away from the actual value (drift) with a visual check of the recorded data at found during checks and/or calibration may least once per batch. Immersing the sensor in an ice slurry Optimal calibration frequency is dependent (32?F (0?C)) if the device will be used at upon the type, condition, past performance, or near refrigeration temperature; and conditions of use of the device. Note that frequent calibration or the need to replace the temperature should be adjusted to the device (perhaps with a more durable compensate for altitude, when necessary; device). Take the following corrective action to regain control over the operation after a critical limit deviation: What Will Be Monitored? This check can be accomplished limits have been met consistently, may by: be performed by any person who has an Immersing the sensor in an ice slurry understanding of the nature of the controls. Note that allowance for routine may be appropriate if they are recommended refrigeration defrost cycles may be by the instrument manufacturer and the necessary. Also note that you may history of use of the instrument in your choose to set a critical limit that specifes facility has shown that the instrument a time and temperature of exposure to consistently remains accurate for a longer temperatures above 40?F (4. The continuously surrounded by ice device should be checked to ensure that it throughout the storage time. In addition to checking that transportation records that show that the device is accurate by one of the methods the product was held at or below 40?F described above, this process should include (4. Note that a visual examination of the sensor and any allowance for routine refrigeration attached wires for damage or kinks. Optimal calibration frequency is dependent There is an adequate quantity of cooling upon the type, condition, past performance, media that remain frozen to have and conditions of use of the device. Receiving records showing: product containers, unless there are Results of continuous temperature fewer than 12 product containers in a monitoring: lot, in which case measure all of the containers. Printouts, charts, or readings of temperature variability may require a from continuous temperaturelarger sample size. The number of containers examined Monitoring is performed by the device and the suffciency of ice for each; itself. In of fsh to ensure that the ice or is suffcient addition to checking that the device is to maintain product temperatures at 40?F accurate by one of the methods described (4. For suitability of use: also be designed to produce an alert Review performance data; indicator. The accuracy of over the operation after a critical limit deviation: the device can be checked by comparing.

It can be decontaminated with soap and water and any contaminated food should be destroyed treatment 002 buy genuine benazepril online. Such toxins are referred to medicine for the people order 10mg benazepril free shipping as exotoxins as they are excreted from the organism medications vertigo cheap benazepril 10mg fast delivery, and as they normally exert their effects on the intestines symptoms sleep apnea buy benazepril 10mg with mastercard, they are called enterotoxins. This toxin causes a markedly different clinical syndrome when inhaled than it characteristically produces when ingested. Often these outbreaks occur in a setting such as a church picnic or other community event, due to common-source exposure in which contaminated food is consumed. They are produced in culture medium and also in foods when there is overgrowth of the organisms. This leads to the direct stimulation of large 98 populations of T-helper cells while bypassing the usual antigen processing and presentation. This induces a brisk cascade of pro-inflammatory cytokines (such as tumor necrosis factor, interferon, interleukin-1 and interleukin-2), with recruitment of other immune effector cells, and relatively deficient activation of counter-regulatory negative feedback loops. Initial symptoms after either route may include nonspecific flu-like symptoms such as fever, chills, headache, and myalgias. Oral exposure results in predominantly gastrointestinal symptoms: nausea, vomiting, and diarrhea. Inhalation exposures produce predominantly respiratory symptoms: nonproductive cough, retrosternal chest pain, and dyspnea. Gastrointestinal symptoms may accompany respiratory exposure due to inadvertent swallowing of the toxin after normal mucocilliary clearance, or simply as a systemic manifestation of intoxication. Gastrointestinal symptoms have been seen in ocular exposures in which ingestion was not thought to have occurred. Respiratory pathology is due to the activation of pro-inflammatory cytokine cascades in the lungs, leading to pulmonary capillary leak and pulmonary edema. Fever may last up to 5 days and range from 103 to 106?F, with variable degrees of chills and prostration. The cough may persist up to 4 weeks, and patients may not be able to return to duty for 2 weeks. Conjunctival injection may be present, and postural hypotension may develop due to fluid losses. Chest examination is unremarkable except in the unusual case where pulmonary edema develops. All of these might present with fever, nonproductive cough, myalgia, and headache. Influenza or community-acquired pneumonia should involve 99 patients presenting over a more prolonged time interval. Naturally occurring staphylococcal food poisoning does not present with pulmonary symptoms. Tularemia and plague, as well as Q fever, are often associated with infiltrates on chest radiographs. Other diseases, including hantavirus pulmonary syndrome, Chlamydia pneumonia, and various chemical warfare agents (mustard, phosgene via inhalation) are in the initial differential diagnosis. Respiratory secretions and nasal swabs may demonstrate the toxin early (within 24 hours of exposure). Because most patients develop a significant antibody response to the toxin, acute and convalescent sera should be drawn for retrospective diagnosis. Nonspecific findings include a neutrophilic leukocytosis, an elevated erythrocyte sedimentation rate, and chest x-ray abnormalities consistent with pulmonary edema. Close attention to oxygenation and hydration is important, and in severe cases with pulmonary edema, ventilation with positive end-expiratory pressure, vasopressors and diuretics may be necessary. Acetaminophen for fever, and cough suppressants may make the patient more comfortable. Most patients can be expected to do quite well after the initial acute phase of their illness, but will be unfit for duty for 1 to 2 weeks. A vaccine candidate is nearing transition to advanced development for safety and immunogenicity testing in humans. Effects on the airway include nose and throat pain, nasal discharge, itching and sneezing, cough, dyspnea, wheezing, chest pain, and hemoptysis. Severe intoxication results in prostration, weakness, ataxia, collapse, shock, and death. Diagnosis: the toxin should be suspected if an aerosol attack occurs in the form of "yellow rain" with droplets of variously pigmented oily fluids contaminating clothes and the environment. Soap and water washing, even 4-6 hours after exposure, can significantly reduce dermal toxicity; washing within 1 hour may prevent toxicity entirely. Prophylaxis: the only defense is to prevent exposure by wearing a protective mask and clothing (or topical skin protectant) during an attack. Isolation and Decontamination: Outer clothing should be removed and exposed skin decontaminated with soap and water. Secondary aerosols are not a hazard; however, contact with contaminated skin and clothing can produce secondary dermal exposures. After decontamination, standard precautions are recommended for healthcare workers. Environmental decontamination requires the use of a hypochlorite solution under alkaline conditions such as 1% sodium hypochlorite and 0. They are smallmolecular-weight compounds, and are extremely stable in the environment. They are the only threat-agent toxin that is dermally active, causing blisters within a relatively short time after exposure (minutes to hours). Dermal, ocular, respiratory, and gastrointestinal exposures can be expected after an aerosol attack with mycotoxins. Survival beyond this point allowed for the development of painful pharyngeal / laryngeal ulcerations and diffuse bleeding into the skin (petechiae and ecchymoses), melena, hematochezia, hematuria, hematemesis, epistaxis, and vaginal bleeding. Mycotoxins allegedly were released from aircraft in the "yellow rain" incidents in Laos (1975-81), Kampuchea (1979-81), and Afghanistan (1979-81). It has been estimated that there were more than 6,300 deaths in Laos, 1,000 in Kampuchea, and 3,042 in Afghanistan. These groups were not protected with masks or chemical protective clothing and had little or no capability of destroying the attacking enemy aircraft. These attacks occurred in remote jungle areas, which made confirmation of attacks and recovery of agent extremely difficult. Some investigators have claimed that the yellow clouds were, in fact, bee feces produced by swarms of migrating insects. The structures of approximately 150 trichothecene derivatives have been described in the literature. These substances are relatively insoluble in water but are highly soluble in ethanol, methanol and propylene glycol. The trichothecenes are extremely stable to heat 102 and ultraviolet light inactivation. They retain their bioactivity even when autoclaved; o heating to 1500 F for 30 minutes is required for inactivation. Soap and water effectively remove this oily toxin from exposed skin or other surfaces. Their most notable effect stems from their ability to rapidly inhibit protein and nucleic acid synthesis. Because this cytotoxic effect imitates the hematopoietic and lymphoid effects of radiation sickness, the mycotoxins are referred to as radiomimetic agents. In the alleged yellow rain incidents, symptoms of exposure from all three routes coexisted. Early symptoms beginning within minutes of exposure include burning skin pain, redness, tenderness, blistering, and progression to skin necrosis with leathery blackening and sloughing of large areas of skin. Upper respiratory exposure may result in nasal itching, pain, sneezing, epistaxis, and rhinorrhea. Anorexia, nausea, vomiting, and watery or bloody diarrhea with crampy abdominal pain occur with gastrointestinal toxicity. Eye pain, tearing, redness, foreign body sensation, and blurred vision may follow ocular exposure. Systemic toxicity can occur via any route of exposure, and results in weakness, prostration, dizziness, ataxia, and loss of coordination. The most common symptoms are vomiting, diarrhea, skin involvement with burning pain, redness and pruritis, rash or blisters, bleeding, and dyspnea. A late effect of systemic absorption is pancytopenia, predisposing to bleeding and sepsis.

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Disadvantages are the delayed tim e to treatment tinnitus benazepril 10 mg sale norm al voiding and severe dysuria (8 medications diabetic neuropathy order 10mg benazepril mastercard,12 medications in carry on luggage purchase discount benazepril line,22) symptoms 9 days past iui buy benazepril 10 mg with visa. During the 3-year post-operative follow-up, serious treatm ent-related com plications occurred in 11. All patients had undergone pressure-flow studies at 3 m onths after laser treatm ent: 32 previously obstructed patients were unobstructed. Even after catheter rem oval, an im provem ent in voiding occurs only gradually, and m ost patients do not notice significant benefits until approxim ately 3?4 weeks post-operatively. Since then, several variations and technical and procedural developm ents have been introduced and tested in clinical trials (26). Coagulation necrosis is generated within the adenom a, sparing its urethral surface. As the applicator can be inserted as deeply and as often as necessary, it is possible to coagulate any am ount of tissue at any desired location. Post-procedure, the intraprostatic lesions result in secondary atrophy and regression of the prostate lobes rather than sloughing of necrotic tissue (27). The total num ber of fibre placem ents is dictated by the total prostate volum e and configuration. As a general guideline, one or two placem ents are used for each estim ated 5?10 cm 3 of prostate volum. In general, the sites for fibre placem ent are chosen according to where the bulk of hyperplastic tissue is found (26). All studies reported m arked im provem ents in sym ptom score, peak flow rate, residual urine volum e and prostate volum e (26?31). Pressure-flow studies dem onstrated a sufficient decrease of the intravesical pressure, urethral opening pressure and urethral resistance. W ithin 12 m onths, there were no statistical differences between groups for all the considered param eters. Post-operative irritative sym ptom s have been observed in 5?15% of patients (28,31,34). Post-operative catheterization was required for an average of up to 18 days, although the catheter was rem oved within 10 days in m ore than 70% of cases. No study has reported any occurrence of im potence or sustained incontinence, though retrograde ejaculation was occasionally reported, with an incidence ranging from 0?11. Urethral strictures or bladder neck strictures are not com m on, and have been reported in approxim ately 5% of patients. However, further com parative random ized studies with longer follow-up are needed to assess the durability of this procedure. Prostatectom y using this energy source is a relatively new technique with the first patient reports appearing in 1995 (37,38). The peak power achieved results in intense tissue vaporization and in precise and efficient cutting ability in the prostatic tissue. A continuous flow resectoscope is required with a working elem ent; norm al saline is used as the irrigant. The basic principle of the technique consists of retrograde enucleation of the prostate and fragm entation of the enucleated tissue to allow its elim ination through the operating channel of the resectoscope (38,39). Outcom e, m orbidity, durability and lim itations As this technique is relatively new, only a few studies with a short follow-up have been published to date. Unfortunately, the longest available follow-up is only 12 m onths, which has confirm ed the short-term durability of the procedure (36). Post-operative dysuria is the m ost com m on com plication, with an incidence of approxim ately 10% (38,40,42). No m ajor com plication has been described; however, the technique is a surgical procedure that requires significant endoscopic skill and cannot be considered easy to learn. Conversely, there are no specific lim itations to the procedure; the size of the prostate that can be treated depends on the experience and patience of the urologist, although the presence of a prostate gland over 100 m L is a relative contraindication in urologists early experience (38). Patients on anticoagulant m edication and those with urinary retention can be safely treated (43). Retrograde ejaculation occurs in 75?80% of patients; no post-operative im potence has been reported (38). Pathologic changes occurring in the prostate following transurethral laser prostatectom y. Transurethral ultrasound-guided laser-induced prostatectom y: objective and subjective assessm ent of its efficacy for treating benign prostatic hyperplasia. A prospective random ized com parison of transurethral resection to visual laser ablation of the prostate for the treatm ent of benign prostatic hyperplasia. Anson K, Nawrocki J, Buckley J, Fowler C, Kirby R, Lawrence W, Paterson P, W atson G. A m ulticenter, random ized, prospective study of endoscopic laser ablation versus transurethral resection of the prostate. High-energy visual laser ablation of the prostate in m en with urinary retention: pressure flow analysis. A new technique of subsurface and interstitial laser therapy using a diode laser (wavelength = 1000 nm) and a catheter delivery device. A random ized prospective m ulticenter study evaluating the efficacy of interstitial laser coagulation. Initial results of a random ized trial com paring interstitial laser coagulation therapy to transurethral resection of the prostate. If the site-intensity is set below the tissue cavitation threshold, the predom inant therapeutic effect is the induction of heat. In order to create a clinically useful volum e of necrosis, a m ultiplicity of laterally or axially displaced individual lesions is generated by physical m ovem ent of the sound-head. Haem atosperm ia for 4?6 weeks is observed in up to 80% of sexually active m en, and patients frequently discharge two to three drops of blood prior to m icturition for several weeks. No cases of urethral strictures, incontinence or the need for blood transfusion have been reported in the literature. In one patient, perforation of the descending colon approxim ately 50?60 cm above the treatm ent zone occurred. It was caused by inadvertent overfilling to 500 m L and subsequent rupture of the condom that covered the ultrasound probe. This com plication led to reconstruction of the filling apparatus and the probe such that the problem can now be reliably avoided. The second severe com plication was a therm olesion of the rectum requiring surgical intervention. This was m ost likely caused by using an inappropriately high-site intensity exceeding 2. To date, several hundred patients have been treated with the Sonablate at various sites. The initial report of the study included 50 patients, 20 of whom were followed up for 12 m onths (5). In the sam e tim e period, the post-void residual urine volum e decreased from 131 ( 120) m L to 48 ( 41) m L at 6 m onths and to 35 ( 30) m L at 12 m onths. Thirty patients underwent urodynam ic investigations (pressure?flow study) before and after a m ean of 4. Pre-operatively, 80% of patients were obstructed and a further 20% were in the interm ediate zone according to the Abram s?Griffith nom ogram. After therapy, a statistically significant decrease in m axim um detrusor pressure, detrusor pressure at Qm ax and linear passive urethral resistance relation was observed. Haem atosperm ia lasting for a m axim um of 4?6 weeks is seen in the m ajority of sexually active patients. Retrograde ejaculation and erectile dysfunction can be safely avoided, although som e patients report a decreased ejaculate volum. The retreatm ent-free period was significantly longer for patients with a pre-treatm ent average flow rate of m ore than 5 m L/s (p = 0. A sim ilar trend, which did not reach statistical significance, was noted for individuals with a higher Qm ax and lower post-void residual urine volum. Im provem ent of urinary sym ptom s is in the range 50?60% and Qm ax increases by a m ean of 40?50%. Long-term efficacy is lim ited, with a treatm ent failure rate of approxim ately 10% per year. High intensity focused ultrasound for the treatm ent of benign prostatic hyperplasia: early United States clinical experience.

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