Transcutaneous electrical nerve stimulation: an effective treatment for refractory non-neurogenic overactive bladder syndrome?

Purpose

To assess the effect of transcutaneous electrical nerve stimulation (TENS) for treating refractory overactive bladder syndrome (OAB).

Patients and methods

A consecutive series of 42 patients treated with TENS for refractory OAB was prospectively investigated at an academic tertiary referral centre. Effects were evaluated using bladder diary for at least 48 h and satisfaction assessment at baseline, after 12 weeks of TENS treatment, and at the last known follow-up. Adverse events related to TENS were also assessed.

Results

Mean age of the 42 patients (25 women, 17 men) was 48 years (range, 18–76). TENS was successful following 12 weeks of treatment in 21 (50 %) patients, and the positive effect was sustained during a mean follow-up of 21 months (range, 6–83 months) in 18 patients. Following 12 weeks of TENS treatment, mean number of voids per 24 h decreased significantly from 15 to 11 (p < 0.001) and mean voided volume increased significantly from 160 to 230 mL (p < 0.001). In addition, TENS completely restored continence in 7 (39 %) of the 18 incontinent patients. Before TENS, all 42 patients were dissatisfied or very dissatisfied; following 12 weeks of TENS treatment, 21 (50 %) patients felt satisfied or very satisfied (p < 0.001). No adverse events related to TENS were noted.

Conclusions

TENS seems to be an effective and safe treatment for refractory OAB warranting randomized, placebo-controlled trials.     

The electrical properties of epidural catheters: what are the requirements for nerve stimulation guidance?

We designed the present study to investigate the electrical resistance of commercially available epidural catheters and to search for products and procedures suitable for nerve stimulation-guided insertion. Four types of epidural catheters were evaluated: 2 nonwire-reinforced catheters (19-gauge and 20-gauge nylon) and 2 wire-reinforced catheters (19-gauge without stylet and 20-gauge with stylet). The resistance of a catheter was calculated from the voltage level proportional to the fixed resistance in series circuit. In case of physiologic saline, the resistance of nonreinforced catheters was more than 700 kOmega, whereas the wire-reinforced catheter was 14.4 +/- 0.20 kOmega without stylet and 10.1 +/- 0.42 kOmega with stylet. When the stylet was passed through a 20-gauge nylon catheter, the resistance decreased to 49.2 +/- 1.96 kOmega. When catheters were primed with 10% hypertonic saline, the resistance of both nonreinforced catheters decreased by one third compared with physiologic saline. The electrical resistance of the saline-filled epidural catheters significantly differed among products tested. We conclude that epidural catheterization that is guided by electrical stimulation should be performed only with catheters equipped with spiral stainless steel wire reinforcement or with a stainless steel stylet.     

Long-term efficacy of strictureplasty for Crohn’s disease

Purpose  

Strictureplasty (SP) is an established surgical option for the management of obstructive Crohn’s disease (CD) to avoid an extended resection. This study reviewed this department’s extensive experience with SP as treatment for obstructive CD to clarify its long-term efficacy and recurrence.     

Long-term safety and efficacy of renin–angiotensin blockade in atherosclerotic renal artery stenosis

Purpose

The activation of the renin?Cangiotensin?Caldosterone system caused by renal ischaemia in atherosclerotic renal artery stenosis (ARAS) may be responsible for serious cardiovascular and renal consequences. The aim of the study was to assess the long-term safety, tolerability and outcomes of the use of angiotensin I-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) in patients with ARAS.

Methods

Thirty-six patients with angiographically defined ARAS (managed either with revascularization or only with medical treatment) were prospectively assessed for the safety, tolerability and outcomes of the use of ACEis or ARBs.

Results

The mean period of follow-up was 88.9?±?37.8?months. A statistically significant reduction in systolic and diastolic blood pressure was recorded over time (P?P?=?0.03). Mean time from diagnosis/intervention to end-stage renal disease for the cohort of 36 patients was 165.38?±?13.62?months. Mean overall patient survival was 135.36?±?15.25?months, with fourteen deaths (38.8%) occurring during the observational period. ACEi/ARB therapy was discontinued transiently in only 4 subjects.

Conclusions

The use of ACEis/ARBs is safe and effective in patients with ARAS independently of any parameters.     

Test–retest reliability of internal pudendal artery blood flow using color Doppler ultrasound in healthy women

Introduction and hypothesis

The internal pudendal artery (IPA) is one of the main arteries supplying the pelvic floor muscles (PFMs) and vulvo-vaginal tissues. Its assessment with color Doppler ultrasound has been documented previously, but the reliability of IPA measurements has never been assessed. This study evaluates the test–retest reliability of IPA blood flow parameters measured by color Doppler ultrasound under two conditions: at rest and after a PFM contraction task.

Methods

Twenty healthy women participated in this study. One observer performed two measurement sessions using a clinical ultrasound system with a curved-array probe on the participant’s gluteal area. IPA measurements were repeated: at rest and after a PFM contraction task. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were measured. Test–retest reliability was assessed using a paired t test, intraclass correlation coefficient (ICC), and Bland and Altman plots.

Results

There was no significant difference for all IPA blood flow measurements between the two repeated sessions. At rest, reliability was excellent for PSV and TAMX and the variability between measurements, as per Bland and Altman plots, was small. After PFM contractions, reliability was excellent for PSV and TAMX and fair to good for PI. The variability between measurements was small for PSV and acceptable for TAMX and PI. EDV and RI parameters did not perform as well.

Conclusion

The assessment of IPA blood flow with color Doppler ultrasound to evaluate vascular change in women is reliable.

     

Is there still a place for the use of nerve stimulation?

The introduction of nerve stimulation as a method of nerve localization sparked a new beginning in regional anesthesia. It was an epochal development akin to the utilization of ultrasound in more recent times. Many experts now consider ultrasound-guided peripheral nerve blockade to be more efficient, less painful, and more successful than landmark and nerve stimulation techniques. However, inadvertent intraneural injection continues to occur despite the widespread use of ultrasound and nerve stimulation. Both of these technologies allow for only limited elucidation of needle position relative to the target nerve and are unable to reliably identify intraneural position of the needle. This article will review the role of nerve stimulation in modern regional anesthesia techniques in light of the introduction of ultrasound technology.     

Percutaneous tibial nerve stimulation in the treatment of refractory overactive bladder syndrome: is maintenance treatment necessary?

OBJECTIVE: To determine the effect of a pause in percutaneous tibial nerve stimulation (PTNS) in successfully treated patients with an overactive bladder (OAB), and the reproducibility of successful treatment when restored. PATIENTS AND METHODS: Eleven patients (mean age 51 years) with refractory OAB (more than seven voids and/or three or more urge incontinence episodes per day) were successfully treated with PTNS, and then discontinued treatment. Patients completed bladder diaries and quality-of-life (QoL) questionnaires (Short Form-36 and I-QoL) before (T1) and after a 6-week pause (T2) of maintenance PTNS, and again after re-treatment (T3). The first objective was defined as a > or = 50% increase in the incontinence episodes and/or voiding frequency in the bladder diary after T2. The second objective was defined as > or = 50% fewer incontinence episodes and/or voiding frequency in bladder diary after T3. RESULTS: At T2, seven of the 11 patients had a > or = 50% increase in incontinence episodes and/or voiding frequency in the bladder diary. The mean voided volume, nocturia, number of incontinence episodes and incontinence severity deteriorated significantly (P < 0.05). At T3, nine patients had > or = 50% fewer incontinence episodes and/or voiding frequency in the bladder diary. Nocturia, the number of incontinence episodes, incontinence severity, mean voided volume and quality of life improved significantly (P < 0.05). CONCLUSIONS: Continuous therapy is necessary in patients with OAB treated successfully by PTNS. The efficacy of PTNS can be reproduced in patients formerly treated successfully.     

Treatment of urinary incontinence in men with electrical stimulation: Is practice evidence-based?

Electrical stimulation is frequently recommended for the treatment of urinary incontinence in men. However, few randomized, controlled trials allow practitioners to evaluate the evidence base for this practice. The purpose of this article is to determine, based on a review of the literature, whether adequate evidence exists to support the use of electrical stimulation as a treatment of male urinary incontinence. Urge, stress, and overflow incontinence are evaluated separately. This review led to 3 conclusions: (1) theoretical and urodynamic evidence exists to support the use of electrical stimulation for urge incontinence, (2) conflicting evidence exists in the use of electrical stimulation for stress urinary incontinence, and (3) treatment of overflow incontinence in men has not been evaluated in a systematic way. For both stress urinary or overflow incontinence, practitioners should consider the existing research before recommending electrical stimulation as a first line of treatment. For urge incontinence, electrical stimulation may be an effective first-line treatment strategy.     

Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children?

Background: Penile nerve block (PNB) is a well‐established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound‐guided PNB versus the classical landmark‐based technique (LBT) in children undergoing circumcision. Methods: Forty boys, aged 1–14 years old that were scheduled for circumcision were randomly assigned to ultrasound‐guided and landmark‐based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg^?1 per side, and 0.05 mg·kg^?1 at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. Results: The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound‐guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US‐guided group (P = 0.001). Conclusion: Ultrasound‐guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.     

Functional electrical stimulation for foot drop in the upper motor neuron syndrome: does it affect 3D foot kinematics during the stance phase of walking?

BackgroundFoot-drop is a common impairment in individuals with upper motor neuron syndrome. It may cause walking instability, and greater risk of tripping and falling. Ankle–foot orthoses are the standard of care for foot-drop, but may constrain ankle movement and limit function. Functional electrical stimulation (FES) was shown to be a less restrictive and effective alternative. Previous studies have addressed the improvement of ankle dorsiflexion during swing and initial contact. However, the foot motion is 3-dimensional and if the stimulation of m. peroneus longus and m. tibialis anterior is not well balanced, excessive eversion or inversion of the foot can occur respectively. Therefore, the objective is to show the effect of FES on foot motion during walking.MethodsSixteen patients with an upper motor neuron syndrome, with a mean age of 15.7 (SD=8.7) years, GMFCS I and II and foot-drop were included. Gait analyses in FES and non-FES conditions were performed at preferred walking speed using the Oxford Foot Model. Differences between conditions were revealed using a t-test.ResultsUse of FES significantly increased peak dorsiflexion in swing phase during walking by 4.7̊ (SD=6.0̊). Eversion of the rearfoot and abduction of the forefoot significantly increased during initial ground contact by 3.7̊ (SD=4.9̊) and 1.9̊ (SD=2.2̊) respectively. This translates to a significant eversion and abduction of 1.4̊ (SD=2.7̊) and 1.3̊ (SD=2.1̊) during stance phase of walking.ConclusionsFES aiming for improved dorsiflexion in swing, increases hindfoot eversion and forefoot abduction that translates into initial contact and persists, although to a lesser extent, during stance phase of walking. The consistent increase in rearfoot eversion may be due to the strategy of choosing higher stimulation intensity and accept exaggerated eversion. While this strategy provides a certain amount of safety and functionality, it affects foot kinematics during stance phase of walking. This can be advantageous for a clubfoot deformity and may have implications for their therapy but deteriorates an existing flatfoot deformity.     

The age at natural menopause and the frequency of climacteric symptoms in Chinese women

IntroductionNaturalmenopauseisconsistentlydefinedasthelastmenstrualperiod.Itisobservedretrospectivelyas12consecutivemonthsofa-menorrheawithuterusandatleastoneovaryintactandwithoutanidentifiablecausefora-menorrheaL1j.Itwasconservativelyestimatedthattherewereabout113.4miIlionwomenatagesof45andaboveinChinaby199OL2j.Ear-lynaturalmenopauseisapotentialbiologicmarkerofhealthandaging.TheageatmenopauseinindividualsmaybeobtainedbyperiodicaIlyaskingwomenaboutthepresenceofmenstrualcyclesL'j.oritmaybed…     

Long-term implantation of deep brain stimulation electrodes in the pontine micturition centre of the Göttingen minipig

Aim

To implant deep brain stimulation (DBS) electrodes in the porcine pontine micturition centre (PMC) in order to establish a large animal model of PMC-DBS.

Method

Brainstems from four Göttingen minipigs were sectioned coronally into 40-μm-thick histological sections and stained with Nissl, autometallographic myelin stain, tyrosin hydroxylase and corticotrophin-releasing factor immunohistochemistry in order to identify the porcine PMC. DBS electrodes were then stereotaxically implanted on the right side into the PMC in four Göttingen minipigs, and the bladder response to electrical stimulation was evaluated by subsequent cystometry performed immediately after the operation and several weeks later.

Findings

A paired CRF-dense area homologous to the PMC in other species was encountered in the rostral pontine tegmentum medial to the locus coeruleus and ventral to the floor of the fourth ventricle. Electrical stimulation of the CRF-dense area resulted in an increased detrusor pressure followed by visible voiding in some instances. The pigs were allowed to survive between 14 and 55 days, and electrical stimulation resulting in an increased detrusor pressure was performed on more than one occasion without affecting consciousness or general thriving. None of the pigs developed postoperative infections or died prematurely.

Conclusions

DBS electrodes can be implanted for several weeks in the indentified CRF-dense area resulting in a useful large animal model for basic research on micturition and the future clinical use of this treatment modality in neurogenic suprapontine voiding disorders.

     

Is there a role for vagus nerve stimulation therapy as a treatment of traumatic brain injury?

This paper aims to review the current literature on vagus nerve stimulation (VNS) use in animal models of traumatic brain injury (TBI) and explore its potential role in treatment of human TBI. A MEDLINE search yielded four primary papers from the same group that demonstrated VNS mediated improvement following fluid percussion models of TBI in rats, seen as motor and cognitive improvements, reduction of cortical oedema and neuroprotective effects. The underlying mechanisms are elusive and authors attribute these to attenuation of post traumatic seizures, a noradrenergic mechanism and as yet undetermined mechanisms. Reviewing and elaborating on these ideas, we speculate other potential mechanisms including attenuation of peri-infarct depolarisations, attenuation of glutamate mediated excitotoxicity, stabilisation of intracranial pressure, enhancement of synaptic plasticity, upregulation of endogenous neurogenesis and anti-inflammatory effects may have a role. Although this data unequivocally shows that VNS improves outcome from TBI in animal models, it remains to be determined if these findings translate clinically. Further studies are warranted.     

Long-term result of guided nerve regeneration with an inert microporous polytetrafluoroethylene conduit

Thedevelopmentinmicrosurgicaltechniqueshasgreatlyimprovednervefunctionalrecovery .However ,owingtotheinabilitytocoaptateandsuturethousandsofnervefiberstotheirfunctionallysimilarnervefibersandinaccuratesutureofthenervestumps ,regeneratednervefiberspartiallylosethechancetoselectivelyregrowintotheirtargetendoneurialtubes,1 4whichresultsinaninevitablemismatchofmotorandsensorynervefibers .Thus,thecontact guidance basedmicrosurgicalnerverepairhasfailedtoachieveconsistentsatisfactoryfunctionalrecover…