Intradetrusor injection of botulinum toxin (BTx) was approved in 2011 by Food and Drug Administration (FDA) for treatment of neurogenic detrusor overactivity only. The off-label use is increasingly common and we have explored its successful use in two varied cases of refractory voiding dysfunction.
About 500,000 vasectomies are performed every year in the US, and an increasing number of men chose this option instead of having their wife go through a more invasive, often intra-abdominal procedure under general anesthesia. Vasectomies are cost-effective, in-office procedures, and usually have a quick recovery.
Austin urologist Dr. Koushik Shaw explains everything you need to know, from the procedure to the recovery. If you're ready for a consultation, you can book an appointment at http://www.austinurologyinstitute.com/.
About 500,000 vasectomies are performed every year in the US, and an increasing number of men chose this option instead of having their wife go through a more invasive, often intra-abdominal procedure under general anesthesia. Vasectomies are cost-effective, in-office procedures, and usually have a quick recovery.
Austin urologist Dr. Koushik Shaw explains everything you need to know, from the procedure to the recovery. If you're ready for a consultation, you can book an appointment at http://www.austinurologyinstitute.com/.
Obstetric fistula is an abnormal opening between the reproductive tract (usually the vagina) and the urinary tract (frequently the bladder) or alimentary tract (usually the rectum) or both. Obstetric fistula typically develops after several days of prolonged or obstructed labour.
Ectopic Pregnancy has certain risks associated with it. Dr Manavita Mahajan explains the risks, diagnosis and management of Ectopic Pregnancy. She is a renowned Gynaecologist and is known all over the world for her professionalism and experience.
Fistula Urogenital o Genitourinario. Historia, definicion, clasificacion, etiologia, manifestaciones clinicas, diagnostico, tratamiento. Imagenes de Urologiaginecologica. Diversos tratamientos y metodos de diagnostico.
Obstetric fistula is an abnormal opening between the reproductive tract (usually the vagina) and the urinary tract (frequently the bladder) or alimentary tract (usually the rectum) or both. Obstetric fistula typically develops after several days of prolonged or obstructed labour.
Ectopic Pregnancy has certain risks associated with it. Dr Manavita Mahajan explains the risks, diagnosis and management of Ectopic Pregnancy. She is a renowned Gynaecologist and is known all over the world for her professionalism and experience.
Fistula Urogenital o Genitourinario. Historia, definicion, clasificacion, etiologia, manifestaciones clinicas, diagnostico, tratamiento. Imagenes de Urologiaginecologica. Diversos tratamientos y metodos de diagnostico.
Botulinum toxin is a neurotoxin produced by Clostridium botulinum species of bacteria. This powerful toxin, which is the most poisonous substance known to mankind, has been used in highly dilute concentrations in urology. This review examines the various applications of botulinum toxin sub-type A (BTA) in the field of Urology.
Current Approach to Overactive Bladder, Issues & Management by Prof. Haleema ...Usman Hingoro
Current Approach to Overactive Bladder, Issues & Management by Prof. Haleema A. Hashmi, Obstetrician & Gynaecology, Liaquat National Hospital & Medical College, Karachi, Pakistan.
Francesca Gottschalk - How can education support child empowerment.pptxEduSkills OECD
Francesca Gottschalk from the OECD’s Centre for Educational Research and Innovation presents at the Ask an Expert Webinar: How can education support child empowerment?
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
The Roman Empire A Historical Colossus.pdfkaushalkr1407
The Roman Empire, a vast and enduring power, stands as one of history's most remarkable civilizations, leaving an indelible imprint on the world. It emerged from the Roman Republic, transitioning into an imperial powerhouse under the leadership of Augustus Caesar in 27 BCE. This transformation marked the beginning of an era defined by unprecedented territorial expansion, architectural marvels, and profound cultural influence.
The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
Under Augustus, the empire experienced the Pax Romana, a 200-year period of relative peace and stability. Augustus reformed the military, established efficient administrative systems, and initiated grand construction projects. The empire's borders expanded, encompassing territories from Britain to Egypt and from Spain to the Euphrates. Roman legions, renowned for their discipline and engineering prowess, secured and maintained these vast territories, building roads, fortifications, and cities that facilitated control and integration.
The Roman Empire’s society was hierarchical, with a rigid class system. At the top were the patricians, wealthy elites who held significant political power. Below them were the plebeians, free citizens with limited political influence, and the vast numbers of slaves who formed the backbone of the economy. The family unit was central, governed by the paterfamilias, the male head who held absolute authority.
Culturally, the Romans were eclectic, absorbing and adapting elements from the civilizations they encountered, particularly the Greeks. Roman art, literature, and philosophy reflected this synthesis, creating a rich cultural tapestry. Latin, the Roman language, became the lingua franca of the Western world, influencing numerous modern languages.
Roman architecture and engineering achievements were monumental. They perfected the arch, vault, and dome, constructing enduring structures like the Colosseum, Pantheon, and aqueducts. These engineering marvels not only showcased Roman ingenuity but also served practical purposes, from public entertainment to water supply.
2. Irreversible binding
to the presynaptic
membrane, producing
a long-lasting paralytic
effect.
Action dose- and
site-specific, may take
24–48 hrs to exert its
effects.
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
3.
Neuropathic bladder conditions
◦ Detrusor overactivity
◦ Detrusor sphincter dysenergia
Bladder overactivity
Painful bladder syndrome
Pelvic pain
Outflow obstruction symptoms
Urinary retention
Intradetrusor injection of BTx was approved in 2011
by FDA for neurogenic detrusor overactivity only,
but the off-label use is increasingly common.
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
4. 9 ½ Years girl
K/C of Langerhan’s Histocytosis ( on & off steroids)
PRESENTING COMPLAINTS (March 2009)
Recurrent UTI
Nocturnal Enuresis
Daytime incontinence
Difficulty in passing urine
PAST H/O
Gross haematuria in 2009 (USG KUB / CECT - mild diffuse
thickening of bladder wall ?Cystitis)
CPE +urethral dilatation in 2010 (DMSA/ DRCG/KFT – WNL)
Protenuria suggestive of ? Ig A Nephropathy/ Nephrotic
Syndrome
PHYSICAL EXAMINATION Normal
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
5.
Micturating cystourethrogram (2010)- no reflux, no
urethral obstruction
MRI Spine - normal
USG KUB - B/L mild HUN, persisting post void
Thickened & irregular bladder wall
PVR 126 cc
Failed trial of antimuscarinics & alpha blockers,
biofeedback and other conservative management.
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
6. Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
7. Sensation
-2 cmH2O
48 cc
29 cmH2O
Normal
desire
70 cc
43 cmH2O
Strong desire
91 cc
159 cmH2O
Max cyst
capacity
91 cc
158 cmH2O
180 cc
71 cc
Peak flow rate
21 cc
First desire
Voided volume
Pdet
First
sensation
Total bladder capacity
Bladder
filling
3 ml/s
Pdet at peak flow
8 cmH2O
Average flow rate
3 ml/s
Residual Urine
109 ml
Opening Pdet
12
cmH2O
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
8. Refractory idiopathic
detrusor overactivity with
superimposed
dysfunctional voiding
(non-neuropathic bladdersphincter dysfunction )
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
9. Sensation
7 cmH2O
84 cc
14 cmH2O
Normal desire
88 cc
16 cmH2O
Strong desire
110 cc
32 cmH2O
Max cyst
capacity
110 cc
33 cmH2O
110 cc
73 cc
Peak flow rate
42 cc
First desire
Voided volume
Pdet
First
sensation
Total bladder capacity
Bladder
filling
6 ml/s
Pdet at peak flow
33 cmH2O
Average flow rate
3 ml/s
Residual Urine
37 ml
Opening Pdet
24 cmH2O
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
10. 48 years librarian
K/C of Interstitial Cystitis Dx on Cystoscopy + bladder biopsy
(2/8/10)
PRESENTING COMPLAINTS (May 2011)
Severe dysuria
Frequent urination
Feeling of incomplete emptying of bladder
Poor flows
PAST H/O
Urethral dilatation in 2000
Failed conservative ( lifestyle & diet modification), medical
management (Amitryptalline/PMSO) and Intravesical
instillation therapies
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
11. Sensation
2 cmH2O
65 cc
2 cmH2O
Normal desire
79 cc
2 cmH2O
Strong desire
88 cc
3 cmH2O
Max cyst
capacity
104 cc
5 cmH2O
106 cc
55 cc
Peak flow rate
59 cc
First desire
Voided volume
Pdet
First sensation
Total bladder capacity
Bladder
filling
3 ml/s
Pdet at peak flow
19 cmH2O
Average flow rate
2 ml/s
Residual Urine
51 ml
Opening Pdet
15 cmH2O
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
12. Painful bladder Syndrome/IC
(hypersensitive low capacity
bladder)
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
13. Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
14.
200 units diluted with
20mls of normal saline
Given as 1 ml
injections at 20
different sites
including trigone*
Fig. 1. Injection technique for BoNT into the overactive bladder
Dae Kyung Kim et al Urol Clin N Am 33 (2006) 503-510
*Kuo HC (2011) Bladder base/trigone injection is safe and as effective as
bladder body injection of onabotulinumtoxinA for idiopathic detrusor
overactivity refractory to antimuscarinics. Neurourol Urodyn 30:1242–1248
*Pinto R et al (2010) Trigonal injection of botulinum toxin A in patients with
refractory bladder pain syndrome/interstitial cystitis. Eur Urol. Sep;58(3):360-5
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
15. Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
16.
Minor effects (Karsenty et al, 2008)
◦
◦
◦
◦
◦
most frequent
injection site pain
procedure-related urinary tract infection
mild hematuria
Increase in PVR
Severe effects (Systemic)
◦
◦
◦
◦
◦
◦
Very rare
Drug reaction - rash of a flu- like illness
Nausea, vomitting
dysphagia, diplopia, blurred vision
Mouth & respiratory weakness
periheral muscle weakness
Contraindications
◦ pre-existing neuromuscular conditions
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
17.
Linda Brubaker et al (2012) Treatment satisfaction and goal attainment
with onabotulinumtoxinA in patients with incontinence due to idiopathic
OAB Int Urogynecol J 23:1017–1025
Denys P et al (2012) Efficacy and Safety of Low Doses of
OnabotulinumtoxinA for the Treatment of Refractory Idiopathic Overactive
Bladder: A Multicentre, Double-Blind, Randomised, Placebo-Controlled
Dose-Ranging Study. Eur Urol 61:520–529
Rovner E et al (2011) Urodynamic results and clinical outcomes with
intradetrusor injections of onabotulinumtoxin A in a randomized, placebocontrolled dose-finding study in idiopathic overactive bladder. Neurourol
Urodyn 30:556–562
Duthie JB et al (2011) Botulinum toxin injections for adults with overactive
bladder syndrome. Cochrane Database Syst Rev (12):CD005493
Dmochowski R et al (2010) Efficacy and safety of onabotulinumtoxinA for
idiopathic overactive bladder: a double-blind, placebo controlled,
randomized, dose ranging trial. J Urol 184:2416–2422
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
18.
Shiu-Dong Chung et al (2012) Intravesical
OnabotulinumtoxinA Injections for Refractory Painful Bladder
Syndrome. Pain Physician; 15:197-202 • ISSN 1533-3159
Giannantoni A et al (2008) Botulinum A toxin intravesical
injection in patients with painful bladder syndrome: 1-year
followup. J Urol ; 179:1031- 1034.
Giannantoni A et al(2006) Botulinum A toxin intravesical
injections in the treatment of painful bladder syndrome: A
pilot study. Eur Urol ; 49:704-709.
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
19.
No universally accepted dose and technique.
Exact targeted depth of injection remains controversial.
Promising alternative option for varied indications in
future.
Thanks
Dr Amita Jain
Confidential & Proprietary
Any use of material without prior permission is strictly prohibited
20. Medanta Institute of Kidney & Urology
Dr. Amita Jain
Urogynaecology Clinic
12th Floor, OPD Wing,
Medanta -The Medicity
Gurgaon, Haryana -122001, INDIA
Tel: +91 124 4141 414 info@medanta.org www.medanta.org
MOB. +91-9871136110
http://www.urogynecologistindia.in/
http://amitajainurogynaecolgist.blogspot.in/
http://www.linkedin.com/mbox?displayMBoxItem=&itemID=I225857003_75
Editor's Notes
Localized administration produces chemical
denervation by irreversible binding to the presynaptic membrane, producing a long-lasting paralytic effect.
The toxin may take 24–48 h to exert its effects.
After 3–6 months, the axons regenerate, thus reversing the denervation process.
The toxin is dose- and site-specific. The duration of effect will vary considerably depending on how it is used.
Detrusor external sphincter dyssynergia
Detrusor hyperreflexia (neurogenic detrusor activity)
Spastic conditions of the urethral rhabdosphincter
(non-relaxing sphincter)
Chronic prostatic pain (and pelvic floor spasticity)
Interstitial cystitis, motor and sensory urge incontinence
Non-fibrotic bladder outflow obstruction (including treatment of
benign prostatic hyperplasia)
Detrusor underactivity and acute urinary retention in women
