Stress urinary incontinence, defined as the involuntary loss of urine during physical exertion, coughing or sneezing, is a common condition in women and is associated with an impaired quality of life. There are several treatment options, such as pelvic floor muscle training (PFMT) and synthetic midurethral sling (SMUS) operations. Until recently, the sequence of these two modalities (both tested in numerous randomized trials) was clear as, in the absence of direct comparisons, it seemed prudent to put weight on the conservative option as the primary treatment given its almost complete lack of risks. In the light of a newly published head-to-head randomized trial, the evidence for surgery versus physiotherapy as the primary treatment for stress urinary incontinence is reviewed, the data summarized and conclusions drawn for the future management of stress-incontinent women.

Urinary incontinence often impairs quality of life more significantly than other chronic diseases such as hypertension, diabetes or depression. Despite identical symptoms, there are various types of urinary incontinence that have different causes and, therefore, require different therapeutic approaches. Although several effective treatment options are available, many patients are not given such treatments and some suffer from serious consequences of incontinence surgery. An exact urological diagnosis is based upon complete understanding of the different pathogenetic mechanisms and the knowledge of modern treatment options, which is necessary to detect the optimal therapy for each patient.

Faecal incontinence is not rare and most cases can be treated conservatively. Surgical intervention is recommended only if adequate symptom relief is not achieved. Over the last decade, new surgical options have evolved but the results vary substantially. Some have gained broader clinical acceptance based on their efficacy, ease of applicability and risk profile. This article aims to outline methods and results of the surgical techniques that are now frequently applied for anal sphincter insufficiency. In addition, it will put these into the context of a treatment algorithm and present novel techniques that carry potential for the future.

Inverted papilloma of the genitourinary tract is an uncommon neoplasm. Some urothelial carcinomas exhibit prominent inverted growth patterns that may pose a diagnostic dilemma. The presence of multiple inverted papillomas, their frequent recurrence and association with transitional cell carcinoma may lead to conflicting clinical conclusions regarding their biological behaviour and hence there is a need to review the literature. Internet databases including PubMed, Google Scholar, Google and Educus were searched to identify publications on inverted papilloma. Thirty-four publications formed the foundation for this review of the literature. The results revealed that inverted papilloma is a rare endophytic urothelial neoplasm that is most commonly found in the urinary bladder and less commonly in the upper urinary tract and urethra. Inverted papillomas are more common in men than in women and may present with obstructive or irritating voiding symptoms or haematuria. Inverted papilloma of the prostatic urethra may present with perineal pain whereas inverted papilloma of the upper renal tract may present with haematuria and loin pain. Inverted papillomas may be difficult to differentiate from inverted urothelial carcinomas but exhibit an absence of, or only few, atypical cells whereas inverted urothelial carcinomas exhibit atypia. Immunohistochemistry can be of assistance as urothelial carcinomas are positive for Ki-67 and p53, fluorescence in situ hybridization (FISH) and cytokeratin 20; however, inverted papillomas generally do not express these markers. FISH analysis can often detect chromosomal anomalies in urothelial carcinomas, but chromosomal abnormalities are absent in inverted papillomas. Inverted papillomas are endophytic and, when they are completely resected or excised, they do not initially recur; however, urothelial carcinomas recur and may progress. Inverted papillomas rarely coexist with urothelial carcinomas and malignant transformation has rarely been reported in inverted papillomas. Microscopic examination may enable inverted papillomas to be classified as the more common classic trabecular subtype or the glandular subtype.

Plasmacytoid urothelial carcinoma is a new variant of urothelial carcinomas that was added to the World Health Organization (WHO) classification list in 2004; therefore, in view of its rarity, most practitioners may not be familiar with its biological behaviour. Various internet databases were searched to identify cases of plasmacytoid urothelial carcinoma of the urinary bladder in order to document the presentation, investigation, management, treatment and outcome of the disease. In addition, the only reported case of plasmacytoid urothelial carcinoma of the ureter is included. Plasmacytoid urothelial carcinoma of the urinary bladder is a rare variant of urothelial carcinoma and fewer than 100 cases have been reported in the literature. It is an aggressive subtype of urothelial carcinoma with plasmacytoid features and the diagnostic features include mimicking haematolymphoid malignancy, a dyscohesive invasive pattern, eccentric nuclei, evidence of prominent eosinophilic cytoplasm (amphophilic cytoplasm may also be observed) and intracytoplasmic mucin-positive lumina may be present. Patients often present with plasmacytoid urothelial carcinoma at a late stage and exhibit peritoneal surface spread. Mucin stains may reveal intracytoplasmic lumina and plasmacytoid urothelial carcinomas tend to depict immunohistochemical staining characteristics such as keratin positivity [cytokeratin (CK)7 and, at times, CK20], CD138 positivity (many carcinomas, not only plasmacytoid urothelial carcinoma, stain positive for CD138), MUM1 and kappa/lambda light chain negativity, E-cadherin negativity (conventional and micropapillary types of urothelial carcinoma tend to stain positive for E-cadherin and signet-ring cell carcinomas of the bladder tend to stain negative). In the differential diagnosis of plasmacytoid urothelial carcinoma, plasmacytoma must be considered, and immunostaining characteristics can be helpful in the confirmation of the diagnosis in that p63-positive staining and strong keratin would indicate carcinoma. Kappa and lambda in situ hybridization or immunoperoxidase would identify most plasmacytomas. CD138 positivity is expressed by many carcinomas and is, therefore, not helpful, whereas MUM1 preferentially stains plasmacytoma. Plasmacytoid urothelial carcinoma of the urinary bladder has characteristic plasmacytoid morphological features and immunohistochemical staining is helpful in differentiating this tumour from other differential diagnoses. Plasmacytoid urothelial carcinomas are aggressive variants of urothelial carcinomas of the urinary bladder that have been associated with poor prognosis and death of patients following various treatment options including transurethral resection of bladder tumour and/or radical cystectomy, transurethral resection biopsy and/or cystectomy and/or chemotherapy, transurethral resection of bladder tumour, and chemotherapy and/or radiotherapy. Most patients do not survive post treatment; however, there are reports of survival following treatments that have included combination systemic chemotherapy.

Lymphoepithelioma tumours are commonly found in the nasopharynx, and histologically similar lymphoepitheliomas have been found elsewhere in the body, including the urinary bladder. Because of the rarity of lymphoepithelioma-like carcinoma (LELC) of the urinary bladder, most practitioners will be unfamiliar with its presentation, management and outcome. LELC of the urinary tract is just one of the variants of urothelial carcinoma that were added to the World Health Organization (WHO) classification in 2004, characterized by their morphological features and immunohistochemical staining characteristics, and including also the nested, microcystic, micropapillary, plasmacytoid variants. The aim of this article is to briefly outline the features of LELC based on the results of various internet searches. LELC of the urinary bladder is a rare tumour, accounting for 0.4–1.3% of all carcinomas of the urinary bladder, and occurs mainly in adults, with a reported mean age at diagnosis of 67–69 years (range 52–84 years). The majority of patients with LELC of the urinary bladder are men (75%), and fewer than 100 cases have been reported in the literature. Patients with LELC of the urinary bladder mostly present with haematuria and a definitive diagnosis is based on accurate histological interpretation. The morphological features of the tumours and the characteristic immunohistochemical staining are key to the diagnosis. Microscopically, they resemble lymphoepithelioma of nasopharynx and are Epstein–Barr virus negative. The lymphoepithelioma-like component should be > 50% and microscopic examination depicts undifferentiated tumour cells in syncytial sheets with minimal cytoplasm, prominent nucleoli, numerous mitoses and lymphocytes. LELC of the urinary bladder tends to exhibit positive staining for cytokeratin (CK) 7, AE1/AE3, epithelial membrane antigen, and often p53 and B- and T-cell markers. In addition, they exhibit negative staining for CD45/leucocyte common antigen. The differential diagnosis of LELC of urinary bladder includes florid cystitis, large cell undifferentiated carcinoma, lymphoma and small cell carcinoma. These tumours are usually muscle-invasive and often coexist with transitional cell carcinoma and carcinoma in situ. Chronic inflammation may obscure the tumour and cystectomy is usually employed as a treatment method in view of the fact that the tumour may be multifocal with synchronous urothelial carcinoma. There is no consensus on the optimum treatment in view of the rarity of the disease. Nevertheless, there is evidence to suggest that patients with pure or predominant LELC of the urinary bladder should undergo transurethral resection with or without adjuvant cisplatin-based systemic chemotherapy and focal LELC should be treated by radical cystectomy with adjuvant cisplatin-based systemic chemotherapy. After bladder-preserving treatment, the patient should undergo regular follow-up cystoscopies.

Hormone-sensitive lipase (HSL) activity was first identified as an adrenaline-sensitive lipolytic activity in adipose tissue. Hormonal activation of HSL occurs via cAMP-dependent protein kinase, which phosphorylates HSL. HSL is the enzyme responsible for the release of free fatty acids (FFAs) from adipose tissue and, therefore, plays a pivotal role in providing the major source of energy for most tissues. Although its expression is highest in adipose tissue, HSL is also expressed in the adrenal glands, ovaries, testes and, to a lesser extent, in skeletal and cardiac muscle and macrophages. The aim of this article is to describe a modified method of determination of HSL activity and gene expression in 10 mg of frozen human adipose tissue samples obtained by biopsy. The enzymes were extracted from the frozen tissue and activity was tested against a fatty acid-labelled diacylglycerol emulsion. The released fatty acids were extracted using a liquid–liquid partition system. The mean±standard error of the mean (SEM) HSL activity in normal fasting individuals was 2.38±0.75 milliunits (mU) oleate/min/g at 37°C. HSL mRNA levels were assessed in 10 mg of adipose tissue using a competitive reverse transcriptase polymerase chain reaction (RT-PCR) assay and the mean ratio of HSL mRNA molecules to β2-microglobulin-mRNA molecules in normal individuals was 0.29±0.04 (mean±SEM). The methods described here are suitable for use in adipose tissue biopsies obtained from normal individuals and provide a means for the examination of the regulation of this enzyme. The importance of this is becoming increasingly apparent, as the inability to suppress lipolysis is associated with conditions of insulin resistance and an increase in propensity to atherosclerosis. This is associated with inappropriate release of FFAs in the postprandial period, resulting in reduced sensitivity of glucose metabolism and increased postprandial lipaemia.

The aim of this article is to document the prevalence of joint hypermobility and joint hypermobility syndrome (JHS) among young adults (aged 16–45 years) in a previously unstudied Middle Eastern population using observational and consecutive case studies. From 1 March to 1 April 2007, 222 young Omani men and women were interviewed at the Sohar Regional Hospital in Sohar, Oman, and examined for the five recognized features of hypermobility (i.e. laxity of the thumbs, little fingers, elbows, spine and knees) as well as 15 other musculoskeletal features. Approximately 45% of the study cohort had at least one lax joint, but only 4% possessed all five features of JHS and JHS could be diagnosed in only 6.3% of subjects. The women studied were older than the men (P<0.001), more overweight (P<0.05) and almost twice as likely to have JHS. A very high frequency (86%) of Marfanoid features was found among subjects with joint hypermobility. JHS in association with Marfanoid features appears to be a cause of musculoskeletal problems in Oman that is frequently unrecognized and may be almost twice as common in women than men.

Hepatic stellate cells (HSCs) are involved in the invasiveness of cancer cells through transdifferention into myofibroblast-like cells, which are characterized by the expression of alpha-smooth muscle actin [α-SMA (Abcam, Cambridge, UK)]. The aim of the present study is to examine whether the HT-29 metastatic colon cancer cell line and Colo-741 non-metastatic colon cancer cell line influence the activation, transdifferentiation and survival of HSCs. Quiescent HSCs (qHSCs) were isolated and identified by vitamin A autofluorescence, Oil red O lipid staining and glial fibrillary acidic protein (GFAP) expression. The duration of qHSC transdifferention was determined using immunocytochemistry via sequential staining of α-SMA and Oil red O on plastic cultures at days 1, 3 and 5. Immunocytochemistry was performed to quantitatively examine the expression of α-SMA in the metastatic and non-metastatic colon cancer cell lines. α-SMA expression was observed for a period of 10 days and the Ki-67 proliferation assay was investigated on day 1 of qHSCs co-culture with HT-29 or Colo-741 conditioned medium. In addition, we examined a caspase-cleaved fragment of cytokeratin (CK)-18 in the qHSCs of these co-cultures. The duration of qHSC transdifferention into myofibroblast-like cells was detected by α-SMA on day 5, whereas lipid droplets, which represent the quiescent phase, were detected up to day 3 only. We found expression of α-SMA at day 1 in the HT-29 co-culture, which increased consistently throughout the duration of the experiment. In contrast, α-SMA was observed only on days 7 and 10 in the Colo-741 co-culture. Using the Ki67 proliferated assay, we could determine that the stellate cells had proliferated in the HT-29 conditioned medium, whereas the Colo-741 conditioned medium did not show any changes. However, by using CK18, it was noted that Colo-741 were found to be significantly proapoptotic. These findings show that the metastatic cell line accelerates transdifferentiation whereas the non-metastatic cell line retards it. In addition, the non-metastatic cell line induced higher levels of apoptosis in myofibroblast-like cells, providing further evidence for a positive role of stellate cells in the metastatic process rather than simply acting to provide a pseudocapsule between the tumour and liver parenchyma, as previously thought.

The risk of diabetes and obesity is recognized as a public health concern within the United Arab Emirates (UAE) and interventions such as physical activity are required to reduce the prevalence of such non-communicable diseases. The aim of this study was to examine the effect of a structured physical activity intervention programme in an overweight Emirati school-based population. Twenty three (n=23) overweight Emirati, male natives (mean±standard deviation: age 14±3 years, stature 157±17 cm, body mass 69±26 kg, body mass index (BMI) 28±6 kg/m2 and V_O2peak 33±7 ml/kg/min) participated in 60 minutes of exercise training a day, 5 days per week, for 12 weeks. All exercise sessions were planned, non-competitive and led by an expert physical education teacher. Primary outcome measures were an increase in cardiorespiratory fitness and a decrease in body mass, blood glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol and triglyceride concentration. Secondary outcomes were reducing were arterial stiffness, body mass index, blood pressure (BP) and increasing whole-body strength. Relative to the baseline, there was a change in body weight and cardiorespiratory fitness (P≤0.05 vs. post intervention, n=23). Although there was a clear trend for statistical change over time in blood glucose, total cholesterol, LDL cholesterol and in triglyceride concentration, there was no difference between baseline and post intervention (P≥0.05). A plausible explanation for the change in fitness following exercise training may be related to a change in body mass or adaptations at the muscle cell level and/or significant cardiovascular structural change. For any biochemical statistical change to occur as a function of exercise training, a larger sample size may be required. In conclusion, the 12-week exercise intervention produced positive changes in cardiorespiratory fitness and body weight in a school-based population and this is the first study of its kind within the UAE. Full-scale interventions targeting the risk of cardiovascular disease and type 2 diabetes mellitus in all populations within the UAE are urgently required.

The use of folic acid supplements prior to, and during, the first months of pregnancy significantly reduces the risk of fetal neural tube defects (NTDs). The aim of this study was to ascertain the awareness and knowledge of the benefits and use of preconception folic acid supplements among Emirati women. This was a cross-sectional study carried out among Emirati women of child-bearing age who were resident in the Al Ain District, Abu Dhabi, United Arab Emirates. Data were collected from October 2011 until March 2012. A convenience sample of women was invited to participate in this study and asked to fill out a questionnaire that requested details of their age, level of education, internet use, marital status, employment and knowledge and attitude towards the use, benefits and administration of folic acid. The collected data were subjected to statistical analysis using SPSS (SPSS Inc., Chicago, IL, USA). The total number of women included in this study was 205, and only 85 women (41.5%) revealed that they were aware of the importance of preconception folic acid. Only 23 women (11.2%) thought that folic acid should be taken before pregnancy. Women with a higher level of education and those > 31 years old had a greater knowledge regarding the time of administration of folic acid than women with lower level of education and those < 31 years old. The awareness and knowledge of the benefits and use of folic acid supplements among Emirati women remains low and further efforts are required to educate women of these supplements.

A case of postpartum haemorrhage due to major placenta praevia with a mild degree of accreta and thrombocytopenia is presented. The baby was delivered via emergency caesarean section that was successfully managed by bilateral uterine artery ballooning followed by embolization, which saved the patient's life and preserved her fertility.

Sacrococcygeal teratoma is one of the most common tumours affecting newborns and infants. Currently, a diagnosis is most likely to be made in the prenatal period during routine ultrasonography examination. Delay in diagnosis and treatment may lead to the development of complications, fetal loss and increased perinatal mortality. This case report investigates rupture of the tumour at birth, one of the complications of sacrococcygeal teratoma. The baby in this case survived and showed a good postoperative recovery.

Laparoscopic sleeve gastrectomy (LSG) is an effective method of treating patients suffering from morbid obesity. The perioperative care of these patients can be complicated by physiological derangement, comorbidities, problems with the patient's airway and alterations in pharmacokinetics and pharmacodynamics of some drugs. We report a case of a 45-year-old man with body weight of 252 kg and body mass index (BMI) of 77 kg/m2 who underwent LSG. This case investigates possibly the most overweight patient to undergo general anaesthesia in the United Arab Emirates (UAE). Specific protocols in anaesthetic management and perioperative care should be implemented to allow effective and safer treatment in obese patients.

Glanzmann's thrombasthenia (GT) is a rare genetic disorder characterized by a lack of platelet aggregation and subsequent bleeding as a result of the absence or dysfunction of the platelet glycoprotein IIb/IIIa complex. We report a case of a 22-year-old woman presenting with massive pelvic haemorrhage after ovarian cyst rupture. This is an unusual complication of this disorder and only two cases have been reported in the literature to date. The patient was managed conservatively with blood transfusion, tranexamic acid and the combined hormone pill. This case highlights the importance of haematologist involvement in patient care and supportive medical management before embarking on surgical interference in cases of coagulation disorders.