A population based cross-sectional time series analysis was conducted using three Ontario administrative databases, to assess trends over time in the surgical management of kidney stone disease. All kidney stone treatments performed with extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy between July 1, 1991 and December 31, 2010, were included. Time series modeling with exponential smoothing and autoregressive integrated moving average models demonstrated a significant increase in the utilization of URS over time (23.69% to 59.98%, p<0.0001), with a reciprocal significant decrease in the utilization of SWL (68.77% to 33.36%, p<0.0001). As a result of this shift in treatment paradigm, time series modeling also demonstrated an associated significant decrease in the need for ancillary treatment over time (22.12% to 16.01%, p<0.0001) and a significant increase in the need for hospital readmission (8.01% to 10.85%, p<0.0001) or emergency room visit (7.58% to 9.95%, p=0.0024) within 7 days following treatment.

A population based cross-sectional time series analysis was conducted using three Ontario administrative databases, to assess trends over time in the surgical management of kidney stone disease. All kidney stone treatments performed with extracorporeal shockwave lithotripsy (SWL), ureteroscopy (URS) and percutaneous nephrolithotomy between July 1, 1991 and December 31, 2010, were included. Time series modeling with exponential smoothing and autoregressive integrated moving average models demonstrated a significant increase in the utilization of URS over time (23.69% to 59.98%, p<0.0001), with a reciprocal significant decrease in the utilization of SWL (68.77% to 33.36%, p<0.0001). As a result of this shift in treatment paradigm, time series modeling also demonstrated an associated significant decrease in the need for ancillary treatment over time (22.12% to 16.01%, p<0.0001) and a significant increase in the need for hospital readmission (8.01% to 10.85%, p<0.0001) or emergency room visit (7.58% to 9.95%, p=0.0024) within 7 days following treatment.

In cell culture, the cellular responses on Day 6 and Day 18, and matrix mineralization (Day 35) of human periosteal cells after stimulated by ESW, LIPUS and ESW+LIPUS treatments were studied. Our results showed that LIPUS only exerted transiently beneficial effects on Day 6, but no effect was observed on Day 18. In contrast, ESW inhibited the differentiation on Day 6, and then exerted a time-delayed stimulation effect on cellular response and matrix mineralization. Data of the ESW+LIPUS showed that it was mainly under ESW effects, but LIPUS might impact the beneficial effect of ESW on Day 18, leading to reduced ALP and matrix mineralization. The potentials of the osteocytes to function as mechanosensors and signal relay were also investigated with untreated periosteal cells that separately received conditioned medium from MLO-Y4 osteocyte-like cells, which received the ESW LIPUS and ESW+LIPUS treatments. The periosteal cells showed stimulated proliferation in the ESW+LIPUS and ESW groups, indicating that the stimulus of ESW was transferred in the conditioned medium. / In conclusion, although our in vivo and in vitro findings did not support our hypothesis of the beneficial effects of combined treatment, but ESW had been shown to improve BMD and bone microarchitecture in osteoporotic bone, by stimulation of osteogenic activities in osseous cells. ESW might potentially be developed as treatment for osteoporosis. Our study also indicated that stimulation of osteogenic activities may be the direct interaction of ESW on osteoblast/periosteal cells, or indirectly through biochemical signals relayed by the osteocytes which acted as mechanosensors. / Osteoporosis is a bone disorder with decreased bone mass and deteriorated microarchitecture, leading to increased fracture risk. By using non-invasive biophysical interventions that stimulate osteogenesis, i.e. extracorporeal shockwave (ESW) and low-intensity pulsed ultrasound (LIPUS), may reduce bone loss effectively. We hypothesized that the combined treatment of ESW and LIPUS might produce synergistic effects on osteoporotic bone. The aim of this study was to investigate the efficacy of using ESW treatment alone and combined treatment of ESW and LIPUS to increase bone mineral acquisition on intact osteoporotic bone in vivo, and to investigate their underlying mechanisms in vitro. / Ten osteoporotic goats were used and divided into ESW and ESW+LIPUS groups (n=5). The ESW group received shockwave at calcaneus, distal radius, and femoral condyle on the left limbs once per month. The ESW+LIPUS group also received ESW treatment monthly and LIPUS for 6 day/week. The opposite limbs served as contralateral control. After nine months, percentage BMD changes, mineral apposition rate, trabecular thickness in treatment sites were found higher than that of controls in both groups. Cumulatively increase of serum bone-specific alkaline phosphatase indicated that the improvements were due to the increased osteogenic activities in bone. Of all parameter, no significant difference was found between the ESW+LIPUS and ESW groups. / by Tam Kam Fai. / "August 2006." / Adviser: Kwok Sui Leung. / Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1550. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (p. 156-184). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstracts in English and Chinese. / School code: 1307.

<p>In this dissertation work, the aim was to garner better mechanistic understanding of how shock wave lithotripsy (SWL) breaks stones in order to guide design improvements to a modern electromagnetic (EM) shock wave lithotripter. To accomplish this goal, experimental studies were carefully designed to isolate mechanisms of fragmentation, and models for wave propagation, fragmentation, and stone motion were developed. In the initial study, a representative EM lithotripter was characterized and tested for in vitro stone comminution efficiency at a variety of field positions and doses using phantom kidney stones of variable hardness, and in different fluid mediums to isolate the contribution of cavitation. Through parametric analysis of the acoustic field measurements alongside comminution results, a logarithmic correlation was determined between average peak pressure incident on the stone surface and comminution efficiency. It was also noted that for a given stone type, the correlations converged to an average peak pressure threshold for fragmentation, independent of fluid medium in use. The correlation of average peak pressure to efficacy supports the rationale for the acoustic lens modifications, which were pursued to simultaneously enhance beam width and optimize the pulse profile of the lithotripter shock wave (LSW) via in situ pulse superposition for improved stone fragmentation by stress waves and cavitation, respectively. In parallel, a numerical model for wave propagation was used to investigate the variations of critical parameters with changes in lens geometry. A consensus was reached on a new lens design based on high-speed imaging and stone comminution experiments against the original lens at a fixed acoustic energy setting. The results have demonstrated that the new lens has improved efficacy away from the focus, where stones may move due to respiration, fragmentation, acoustic radiation forces, or voluntary patient movements. Using traditional theory of brittle fragmentation and newfound understanding of average peak pressure correlation to stone comminution, the entire set of stone comminution data for lens comparison was modeled using a Weibull-style distribution function. This model linked both the average peak pressure and shock wave dose to efficacy, including their respective threshold parameters, and demonstrated correlation of coefficients to cavitation activity. Subsequently, this model was used in prediction of stone comminution efficiency from mimicked respiratory motions in vitro, which compared favorably to actual simulated motion studies using both the new and original lenses. Under a variety of mimicked respiratory motions, the new lens produced statistically higher stone comminution efficiency than the original lens. These results were confirmed in vivo in a swine model, where the new lens produced statistically higher stone comminution after 1,000 and 2,000 shocks. Finally, a mechanistic investigation into the effects of cavitation with the original lens was conducted using an integrated, self-focusing annular ring transducer specially designed for tandem pulse lithotripsy. It was found that cavitation and stone comminution efficiency are progressively enhanced by tandem pulsing as source energies of both the primary LSW and trailing pressure pulse increase, which suggests cavitation and stress waves act synergistically enhance the efficacy in kidney stone fragmentation.</p> / Dissertation

The enforcement of national health insurance brings the new transition of medical service. The main purpose of this study is to investigate patients¡¦ emphasis and satisfaction on different dimension of service quality. The study referred to industrial views, related literature review and 5Qs model (Zineldin, 2006). Eventually, the practical research results are used to conduct a competitive niche strategy and a positioning plan of extracorporeal shock wave lithotripsy market to seek the unique value of medical service differentiation. According to the empirical view, the satisfaction and loyalty of those patients who had operations under the hospital treatment were significantly higher than those patients who didn¡¦t. ¡§Quality of atmosphere¡¨ and ¡§Quality of infrastructure¡¨ were the two factors which had positive impact on the satisfaction of patients. Also, ¡§Quality of medical care interaction¡¨ and ¡§Quality of atmosphere¡¨ affected the loyalty of patients greatly. Therefore, this study suggested that doctors should provide professional medical services to offer unique attributes which were valued by patients, and then achieved the influence of word-of-mouth marketing. The Competitive strategy is (1) from standardization to differentiation: creating values to patients by standard operation procedure. (2) from selfish departmentalism to patient-orientation: providing more interactions during medical service to fulfill the cognitive and emotional needs of patients. (3) from tradition to innovation: carrying out a new model which was designed by whole new ideas to supply medical service with sustainable competitive advantage. (4) from closed to open environment: emphasizing on profession and abandoning asymmetric information to develop trust relationship between doctors and patients. The strategic positioning of ESWL is to provide cordial, effective and fast integrated medical service for patients, and the establishment of ¡§Shock Wave Lithotripsy Center¡¨ is the further step of this strategy.

The main purpose of this research was to investigate new medical applications of femtosecond laser ablation. A near-infrared femtosecond laser was tested and proved to be able to overcome the existing limitations and outperform the conventional long-pulse lasers in the areas of human urinary calculus (kidney stone) lithotripsy and skin treatment. The two primary objectives of my research are: 1) to investigate the feasibility of using femtosecond pulsed laser radiation to ablate urinary calculus of various compositions. The laser-calculus interaction mechanism was characterized using pump probe imaging and fast flash imaging. A novel fiber delivery system was developed to transmit and focus high energy femtosecond pulses for urinary calculus lithotripsy. The successful demonstration of the femtosecond laser lithotripsy provided a promising treatment method better than the existing long-pulse laser lithotripsy in a few different aspects, including less collateral damage to surrounding tissue, small-size debris and more controlled experimental condition. 2) to investigate the depth limitation of femtosecond subsurface ablation in scattering skin sample and develop a prototype tissue optical clearing device to enhance femtosecond beam penetration for deeper subsurface cavitation production in the skin. The successful demonstration of the device has potential benefits to new femtosecond-based therapies for reshaping or removing subcutaneous tissues. / text

<p>The primary goal of this dissertation was to assess the feasibility of transforming an electromagnetic (EM) shock wave lithotripter with an acoustic lens as its focusing device from the original axisymmetric pressure distribution to a non-axisymmetric steerable acoustic field. This work was motivated by the desire to better match the distribution of effective acoustic pressure and pulse energy with the trajectory and anatomical features around renal and ureteral calculi during clinical shock wave lithotripsy (SWL). The acoustic field transformation was accomplished by the design of a fan-shaped acoustic barrier (mask) placed on top of the lithotripter acoustic lens to selectively reduce the source aperture along the direction of the barrier axis, therefore effectively broadening the beam width (<italic>BW</italic>) of the lithotripter field in this preferred direction. Moreover, the geometry of the original lens (L₁) was modified so that the acoustic focus of the new lens (L₂) at high output voltages (necessitated by the incorporation of the mask) is closely aligned with the lithotripter focus. The mask was further driven by a motor-controlled gear system to rotate around the lithotripter axis, generating a steerable and non-axisymmetric acoustic field. In this dissertation project, a linear acoustic model was first used for parametric studies to assess the effects of mask geometry (opening angle and thickness) on beam elongation and peak pressure reduction. Based on this analysis, two mask geometries (L₂+M₈₀₂₅ and L₂+M₉₀₃₀) were selected for modest and maximum beam elongation within the acceptable output range of the shock wave source. The acoustic and cavitation fields of the new lens with masks, as well as the corresponding field produced by the original lens, were characterized using fiber optical probe hydrophone measurements and stereoscopic high-speed imaging. Different output voltage settings were used for each lens configuration (i.e., 14 kV for L₁, 15.8 kV for L₂+M₈₀₂₅, and 17 kV L₂+M₉₀₃₀) to produce equivalent acoustic pulse energy of 45 mJ in all setups, measured in the lithotripter focal plane. Under this condition, L₂+M₈₀₂₅ and L₂+M₉₀₃₀ generate lower peak pressure (38.2 and 36.8 MPa) with a significantly broadened BW_y (11.4 and 14.3 mm) along the y-axis (head-to-toe direction of the patient), which is aligned with the mask axis, compared to the high peak pressure (44.1 MPa) and moderate <italic>BW</italic> (7.5 mm) of L₁. It is worth noting that L₂+M₈₀₂₅ and L₂+M₉₀₃₀ produce a <italic>BW</italic>_x (7.6 and 7.5 mm) in the orthogonal direction to the mask axis, which is also comparable to L₁. Similarly, the beam width of the cavitation field was broadened from 8.1 to 12.2 mm for L₂+M₈₀₂₅, and from 10.9 to 17.9 mm for L₂+M₉₀₃₀, compared to the range of 8.8 to 9.4 mm measured from L₁. In comparison, L₂+M₈₀₂₅ produces a denser and narrower bubble cloud along the y-axis than L₂+M₉₀₃₀. In vitro stone comminution (<italic>SC</italic>) tests in a tube holder (Diameter = 14 mm) have demonstrated that L₂+M₈₀₂₅ and L₂+M₉₀₃₀ are more effective at off-axis positions and during simulated respiratory motion along the elongated beam direction. The results of <italic>SC</italic> also confirmed the correlation between <italic>SC</italic> and the average peak pressure, p_+(avg), and effective acoustic pulse energy, E_eft, delivered to the stone, as shown in previous studies. Furthermore, a ureter model was developed and used to assess the performance of L₂+M₉₀₃₀, which has the maximally elongated <italic>BW</italic> under various static and simulated respiratory motion conditions. The results suggest that L₂+M₉₀₃₀ can produce significantly better <italic>SC</italic> than L₁ when the elongated beam is effectively aligned with the stone/fragments in the ureter or with their motion trajectory during the course of SWL treatment. Altogether, the results of this dissertation work have demonstrated <italic>in vitro</italic> that a non-axisymmetric and steerable acoustic field can significantly enhance stone comminution under clinically relevant SWL conditions. Future work is warranted to optimize the mask design and steering protocol to maximize the benefit of such an adaptable and versatile design to improve the performance and safety of clinical EM lithotripters.</p> / Dissertation

Introduction: Extracorporeal shock wave lithotripsy (ESWL) is the standard stone treatment. Increased excretion of tubular enzymes and hypercalciuria has been reported after ESWL. We investigated the importance of renally induced hypercalciuria after ESWL. Material and Methods: 30 calcium oxalate stoneformers (23 men, 7 women), mean age 53.3 (range 30–71) years, were evaluated prospectively. Plasma calcium and creatinine concentrations and 8-hour overnight urine were measured before ESWL and on the 1st and 2nd days after ESWL. To estimate the changes of tubular reabsorption, the calcium/creatinine clearance ratios were calculated. Results: Hypercalciuria (>5 mmol/24 h) was seen in 5/30 (16.7%) before, in 12/30 (40.0%) on day 1 and in 13/30 (43.3%) on day 2 after ESWL. The mean plasma levels of calcium were significantly decreased from 2.36 mmol/l before to 2.28 mmol/l on day 2 after ESWL (p< 0.01). The mean calcium/creatinine clearance ratio was significantly increased from 0.012 before to 0.019 after ESWL (p< 0.01). Before and on day 2 after ESWL, the calcium/creatinine clearance ratio was significantly correlated with the age of the patients (r = 0.33, p< 0.04). Conclusion: Our data show an age-related significantly increased urine calcium excretion after ESWL possibly due to decreased tubular calcium reabsorption. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Urolithias, calculus formation in the urinary system, affects 5 – 10% of the population and is a painful and recurrent medical condition. A common approach in the treatment of calculi is the use of laser radiation, a procedure known as laser lithotripsy, however, the technique has not yet been fully optimised. This research examines the experimental parameters relevant to the interactions of the variable microsecond pulsed holmium laser (λ = 2.12 μm, τp = 120 – 800 μs, I ~ 3 MW cm-2) and the Q-switched neodymium laser (λ = 1064 nm, τp = 6 ns, I ~ 90 GW cm-2) with calculi. The laser-calculus interaction was investigated from two perspectives: actions that lead to calculus fragmentation through the formation of shockwave and plasma, and the prospect of material analysis of calculi by laser induced breakdown spectroscopy (LIBS) to reveal elemental composition. This work is expected to contribute to improved scientific understanding and development of laser lithotripsy. The results support the general model of thermal and plasma processes leading to vaporization and pressure pulses. Nd:YAG laser interaction processes were found to be plasma-mediated and shockwave pressure (~ 12 MPa) dependent on plasma and strongly influenced by metal ions. Ho:YAG laser-induced shockwaves (~ 50 MPa) were found to be due to direct vaporisation of water and dependent on laser pulse duration. The characteristics of the pressure pulse waveforms were found to be different, and the efficiency and repeatability of shockwave and the nature of the dependencies for the lasers suggest different bubble dynamics. For the Nd:YAG laser, LIBS has been demonstrated as a potential tool for in situ analysis of calculus composition and has been used for the identification of major and trace quantities of calcium, magnesium, sodium, potassium, strontium, chromium, iron, copper, lead and other elements.

Urolithias, calculus formation in the urinary system, affects 5 – 10% of the population and is a painful and recurrent medical condition. A common approach in the treatment of calculi is the use of laser radiation, a procedure known as laser lithotripsy, however, the technique has not yet been fully optimised. This research examines the experimental parameters relevant to the interactions of the variable microsecond pulsed holmium laser (λ = 2.12 μm, τp = 120 – 800 μs, I ~ 3 MW cm-2) and the Q-switched neodymium laser (λ = 1064 nm, τp = 6 ns, I ~ 90 GW cm-2) with calculi. The laser-calculus interaction was investigated from two perspectives: actions that lead to calculus fragmentation through the formation of shockwave and plasma, and the prospect of material analysis of calculi by laser induced breakdown spectroscopy (LIBS) to reveal elemental composition. This work is expected to contribute to improved scientific understanding and development of laser lithotripsy. The results support the general model of thermal and plasma processes leading to vaporization and pressure pulses. Nd:YAG laser interaction processes were found to be plasma-mediated and shockwave pressure (~ 12 MPa) dependent on plasma and strongly influenced by metal ions. Ho:YAG laser-induced shockwaves (~ 50 MPa) were found to be due to direct vaporisation of water and dependent on laser pulse duration. The characteristics of the pressure pulse waveforms were found to be different, and the efficiency and repeatability of shockwave and the nature of the dependencies for the lasers suggest different bubble dynamics. For the Nd:YAG laser, LIBS has been demonstrated as a potential tool for in situ analysis of calculus composition and has been used for the identification of major and trace quantities of calcium, magnesium, sodium, potassium, strontium, chromium, iron, copper, lead and other elements.