Search

Objectives To assess the efficacy of transcutaneous electrical nerve stimulation (TENS) for neurogenic bladder dysfunction secondary to spinal cord injury (SCI). Materials and methods A systematic search of MEDLINE, EMBASE, Web of Science, Scopus, and Cochrane libraries up to February 2021 was performed using PRISMA methodology. All randomized controlled trials (RCTs) that studied TENS for neurogenic bladder in a SCI population were included. The primary outcomes of interest were maximum cystometric capacity (MCC) and maximum detrusor pressure (Pdet). Meta-analysis was conducted with RevMan v5.3. Results Six RCTs involving 353 participants were included. Meta-analysis showed that TENS significantly increased MCC (standardized mean difference 1.11, 95% confidence interval [CI] 0.08-2.14, p = 0.03, I2 = 54%) in acute SCI. No benefits were seen for maximum Pdet. TENS was associated with no major adverse events. Conclusions TENS may be an effective, safe intervention for neurogenic bladder dysfunction following SCI. Further studies are essential to confirm these results and more work is required to determine optimal stimulation parameters and duration of the treatment.

Objectives Transcutaneous electrical nerve stimulation (TENS) is a noninvasive analgesic neurostimulation modality. Difficulties in clinical trial blinding and therapy administration have limited conclusions of previous trials. The aims of this study were to first investigate the feasibility and acceptability of patient-administered TENS after surgery, and second, the feasibility of using sub-sensory TENS as a proxy sham group for patient-blinding. Materials and methods Over a four-month period, patients undergoing laparoscopic cholecystectomy at a single center were randomized to receive maximally tolerable high-intensity (HI) TENS or sub-sensory low-intensity (LI) TENS. Patients and outcome assessors were blinded. Primary outcomes were the feasibility, tolerability, and acceptability of patient self-administered TENS, measured by patient-reported outcomes, and the strength of patient-blinding, measured using the James Blinding Index (JBI). Secondary outcomes explored clinical recovery and analgesic efficacy. Results Nineteen patients were screened for inclusion; ten patients were randomized and completed the feasibility study. TENS therapy was variably utilized (median duration of TENS 5.3 hours/day [IQR: 4.1-6.9]). The JBI was 0.7, indicating a strong strength of blinding. Majority of patients found the TENS unit easy to use (90%) and were confident with self-administration (100%). No patients experienced adverse effects of TENS use. Conclusions Patient-administered TENS is safe and acceptable. Future studies may use sub-sensory TENS as a proxy sham control to more reliably blind patients. A larger, double-blinded RCT employing these techniques is now needed to determine the analgesic efficacy of TENS in an enhanced recovery setting, and its potential to reduce opiate usage.

BACKGROUND Successful treatments following electrical nerve stimulation have been commonly reported in patients with fecal incontinence and constipation. However, many of these nerve stimulation trials have not implemented sham controls, and are, therefore, unable to differentiate overall treatment responses from placebo. This systematic review aimed to quantify placebo effects and responses following sham electrical nerve stimulation in patients with fecal incontinence and constipation. MATERIAL AND METHODS A literature search of Ovid MEDLINE, PubMed, EMBASE, and Cochrane databases was conducted from inception to April 2017. Randomized sham-controlled trials investigating the effect of lower gastrointestinal electrical nerve stimulation in fecal incontinence and constipation were included. Pediatric and non-sham controlled trials were excluded. RESULTS Ten randomized sham-controlled trials were included. Sham stimulation resulted in improvements in fecal incontinence episodes by 1.3 episodes per week (95% CI -2.53 to -0.01, p = 0.05), fecal urgency by 1.5 episodes per week (CI -3.32 to 0.25, p = 0.09), and Cleveland Clinic Severity scores by 2.2 points (CI 1.01 to 3.36, p = 0.0003). Sham also improved symptoms of constipation with improved stool frequency (1.3 episodes per week, CI 1.16 to 1.42, p

Objectives Postoperative ileus occurs in approximately 5-15% of patients following major abdominal surgery, and poses a substantial clinical and economic burden. Electrical stimulation has been proposed as a means to aid postoperative gastrointestinal (GI) recovery, but no methods have entered routine clinical practice. A systematic review was undertaken to assess electrical stimulation techniques and to evaluate their clinical efficacy in order to identify promising areas for future research. Materials and methods Literature was searched using MEDLINE, EMBASE, Google Scholar and by assessing relevant clinical trial databases. Studies investigating the use of electrical stimulation for postoperative GI recovery were included, regardless of methods used or outcomes measured. A critical review was constructed encompassing all included studies and evaluating and synthesizing stimulation techniques, protocols, and clinical outcomes. Results A broad range of neuromodulation strategies and protocols were identified and assessed. Improved postoperative GI recovery following electrical stimulation was reported by 55% of studies (10/18), most commonly those assessing transcutaneous electrical nerve stimulation and electroacupuncture therapy (7/10). Several studies reported shorter time to first flatus and stool, shorter duration of hospital stay, and reduced postoperative pain. However, inconsistent reporting and limitations in trial design were common, compromising a definitive determination of electrical stimulation efficacy. Conclusions Electrical stimulation appears to be a promising methodology to aid postoperative GI recovery, but greater attention to mechanisms of action and clinical trial quality is necessary for progress. Future research should also aim to apply validated and standardized gut recovery outcomes and consistent neuromodulation methodologies.

Background and Aims High-frequency gastric electrical stimulation (GES) has emerged as a therapy for gastroparesis, but the mechanism(s) of action remain unclear. There is a need to refine stimulation protocols for clinical benefit, but a lack of accurate techniques for assessing mechanisms in clinical trials, such as slow wave modulation, has hindered progress. We thereby aimed to assess acute slow wave responses to GES in gastroparesis patients using high-resolution (HR) (multi-electrode) mapping, across a range of stimulation doses achievable by the Enterra stimulation device (Medtronic Inc., MN, USA). Materials and Methods Patients with medically refractory gastroparesis (n = 8) undergoing device implantation underwent intraoperative HR mapping (256 electrodes). Baseline recordings were followed by four protocols of increasing stimulation intensity, with washout periods. Slow wave patterns, frequency, velocity, amplitude, and dysrhythmia rates were quantified by investigators blinded to stimulation settings. Results There was no difference in slow wave pattern, frequency, velocity, or amplitude between baseline, washout, and stimulation periods (all p > 0.5). Dysrhythmias included ectopic pacemakers, conduction blocks, retrograde propagation, and colliding wavefronts, and dysrhythmia rates were unchanged with stimulation off vs. on (31% vs. 36% duration dysrhythmic; p > 0.5). Symptom scores and gastric emptying were improved at 5.8 month follow-up (p

Introduction Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear. Methods MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE. Results Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons. Conclusion Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE. Preregistration PROSPERO submitted 23 December 2020. CRD42021227637, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to pancreaticoduodenectomy for minimising delayed gastric emptying (DGE). Based on existing RCT evidence, a pylorus resecting, antecolic, Billroth II anastomosis with Braun enteroenterostomy is associated with the lowest rates of DGE after pancreatoduodenectomy.

Fellowships in surgery are increasing in number, and concerns have been raised regarding their impact on resident training. Although fellows may contribute to resident education and training, they also compete for operative and other experience. This study aimed to quantify the impact of fellowships on resident training in a binational multispecialty cohort.The operative case volumes and primary operator rates of surgery trainees (residents) in Australia and New Zealand were compared between units with and without fellows. Trainees also were surveyed using Likert Scales to assess quality of operative and other experience in units with and without fellows.Data from 911 trainees over 2 terms was analyzed; survey response rate 42%. Of all trainees, 42% worked with fellows. Trainees in units without fellows were involved in more major (P = .03) and minor (P.0001) cases. Primary operator rates were comparable, but trainees in units without fellows were less often assistants, reported an increased quality of elective operating experience, and reported more favorable completion of learning objectives (all P.05). These findings were consistent between tertiary and nontertiary hospitals. Thematic analysis showed positive benefits of fellows in teaching, training and mentorship, but negative impacts on case exposure, competition for operating, and clinical experience.Fellows may assist in the teaching and training of residents, but residents working with fellows experience a decreased quantity of operative experience that may impact several aspects of the quality of training. Surgical educators must actively balance the learning needs of fellows and residents.

Gastric arrhythmias occur in gastroparesis but their significance is debated. An improved understanding is currently emerging, including newly-defined histopathologic abnormalities in gastroparesis. In particular, the observation that interstitial cells of Cajal are depleted and injured provides mechanisms for arrhythmogenesis in gastroparesis. Electrogastrography has been the dominant clinical method of arrhythmia analysis, but is limited by summative nature, low signal quality, and incomplete sensitivity and specificity. Recently, high-resolution (HR; multi-electrode) mapping has emerged, providing superior spatial data on arrhythmic patterns and mechanisms. However, HR mapping is invasive, and low-resolution approaches are being assessed as bridging techniques until endoscopic mapping is achieved.

Intracranial aneurysm rupture continues to cause high mortality and morbidity. Determining the aetiology, identifying the risk factors and improving diagnostic accuracy are ongoing challenges. We retrospectively reviewed consecutive autopsies over 30 years (1977-2006) in Auckland, New Zealand, and identified 403 cases of subarachnoid haemorrhage to examine these challenges within a fatal case population. Females (67%) outnumbered males. Ruptured posterior circulation aneurysms were frequent (25%). Left ventricular hypertrophy was documented in 45% of cases, with fatty metamorphosis of the liver also prominent (16%). About 6.5% had additional unruptured aneurysm/s. Most patients were sedentary at onset (39% being asleep); 6% were involved in significant physical exertion; 69% were found dead or collapsed; the remaining patients reported headache (27%) or atypical primary symptoms (4%). Warning headache over recent days to months occurred in 38%, among whom misdiagnosis was notable. Our findings regarding warning headache patterns and the range of atypical presentations are aimed at improving clinician discernment in managing this condition.

Chronic unexplained nausea and vomiting (CUNV) is a debilitating disease of unknown cause. Symptoms of CUNV substantially overlap with those of gastroparesis, therefore the diseases may share pathophysiologic features. We investigated this hypothesis by quantifying densities of interstitial cells of Cajal (ICCs) and mapping slow-wave abnormalities in patients with CUNV vs controls.Clinical data and gastric biopsy specimens were collected from 9 consecutive patients with at least 6 months of continuous symptoms of CUNV but normal gastric emptying who were treated at the University of Mississippi Medical Center, and from 9 controls (individuals free of gastrointestinal disease or diabetes). ICCs were counted and ultrastructural analyses were performed on tissue samples. Slow-wave propagation profiles were defined by high-resolution electrical mapping (256 electrodes; 36 cm(2)). Results from patients with CUNV were compared with those of controls as well as patients with gastroparesis who were studied previously by identical methods.Patients with CUNV had fewer ICCs than controls (mean, 3.5 vs 5.6 bodies/field, respectively; P.05), with mild ultrastructural abnormalities in the remaining ICCs. Slow-wave dysrhythmias were identified in all 9 subjects with CUNV vs only 1 of 9 controls. Dysrhythmias included abnormalities of initiation (stable ectopic pacemakers, unstable focal activities) and conduction (retrograde propagation, wavefront collisions, conduction blocks, and re-entry), operating across bradygastric, normal (range, 2.4-3.7 cycles/min), and tachygastric frequencies; dysrhythmias showed velocity anisotropy (mean, 3.3 mm/s longitudinal vs 7.6 mm/s circumferential; P.01). ICCs were less depleted in patients with CUNV than in those with gastroparesis (mean, 3.5 vs 2.3 bodies/field, respectively; P.05), but slow-wave dysrhythmias were similar between groups.This study defined cellular and bioelectrical abnormalities in patients with CUNV, including the identification of slow-wave re-entry. Pathophysiologic features of CUNV were observed to be similar to those of gastroparesis, indicating that they could be spectra of the same disorder. These findings offer new insights into the pathogenesis of CUNV and may help to inform future treatments.

Aim To investigate the relative importance of both linear and circular polarization parameters, derived from 4x4 Mueller matrix measurements, in discriminating gastric cancer from normal gastric tissues over the visible spectral region from 470 nm to 632 nm. Methods A total of 46 tissue samples, obtained from 40 patients, were examined in this study, in which 26 normal gastric samples were obtained as endoscopic biopsies while 20 gastric cancer samples were obtained from gastrectomy. Informed consent was obtained before tissue samples were used in this study. For multiple normal samples from one single patient, the values of polarization parameters were averaged to represent only one sample in each classification. This yielded a total of 20 sets of data for normal samples and 20 sets of data for cancer samples, one set for each patient. Each sample was fixed using 10%-formalin solution before it was embedded in paraffin. Then two 4-μm vertical sections immediately next to each other were made in the sample. One tissue section was routinely stained with Hematoxylin and Eosin (H&E) to generate a pathological report. The other tissue section was not stained, which was placed on a microscope slide without a cover slip for polarimetry measurements. Results The studied polarization parameters were retardance, diattenuation and depolarization of normal and cancerous gastric samples at nine wavelengths from 470 nm to 632 nm. The average retardance of normal samples was smaller than that of cancer samples. There was no overlap in the error bars between normal samples and cancerous samples at all nine wavelengths, suggesting that retardance could be used to effectively differentiate normal and cancer samples. In contrast, there were significant overlaps in the error bars of diattenuation and depolarization between normal and cancer samples at all wavelengths. It was found that the combination of linear depolarization and linear retardance showed the highest overall accuracy (95.00%) among all the possible combinations of two parameters. This combination also demonstrated considerable improvement in overall accuracy compared to that for either linear retardance (82.50%) or linear depolarization (77.50%) alone. Conclusion There were significant differences in most polarization parameters between normal and cancer tissue samples. The combination of linear depolarization and linear retardance yielded the highest accuracy in sample classification.

Interstitial cells of Cajal (ICC) generate slow waves. Disrupted ICC networks and gastric dysrhythmias are each associated with gastroparesis. However, there are no data on the initiation and propagation of slow waves in gastroparesis because research tools have lacked spatial resolution. We applied high-resolution electrical mapping to quantify and classify gastroparesis slow-wave abnormalities in spatiotemporal detail.Serosal high-resolution mapping was performed using flexible arrays (256 electrodes; 36 cm(2)) at stimulator implantation in 12 patients with diabetic or idiopathic gastroparesis. Data were analyzed by isochronal mapping, velocity and amplitude field mapping, and propagation animation. ICC numbers were determined from gastric biopsy specimens.Mean ICC counts were reduced in patients with gastroparesis (2.3 vs 5.4 bodies/field; P.001). Slow-wave abnormalities were detected by high-resolution mapping in 11 of 12 patients. Several new patterns were observed and classified as abnormal initiation (10/12; stable ectopic pacemakers or diffuse focal events; median, 3.3 cycles/min; range, 2.1-5.7 cycles/min) or abnormal conduction (7/10; reduced velocities or conduction blocks; median, 2.9 cycles/min; range, 2.1-3.6 cycles/min). Circumferential conduction emerged during aberrant initiation or incomplete block and was associated with velocity elevation (7.3 vs 2.9 mm s(-1); P = .002) and increased amplitudes beyond a low base value (415 vs 170 μV; P = .002).High-resolution mapping revealed new categories of abnormal human slow-wave activity. Abnormalities of slow-wave initiation and conduction occur in gastroparesis, often at normal frequency, which could be missed by tests that lack spatial resolution. Irregular initiation, aberrant conduction, and low amplitude activity could contribute to the pathogenesis of gastroparesis.

Introduction Gastric smooth muscle layers are electrically excited by slow waves. In the normal stomach, slow waves propagate longitudinally in ring wavefronts from the upper corpus to the distal antrum. Circumferential propagation does not appear to occur, likely because there is no excitable tissue available circumferentially in these rings. However, rapid circumferential propagation has been observed in isolated gastric tissues and during gastric pacing. In this study, the propagation profiles of slow wave behaviors in diabetic gastroparesis were defined at high resolution (HR). The hypothesis was that circumferential propagation occurs during dysrhythmia, presenting a novel marker of gastric electrical dysfunction. Methods HR (multi-electrode) mapping was performed in 7 patients with diabetic gastroparesis undergoing laparotomy for stimulator implantation. Anterior serosal recordings were taken using flexible PCB arrays (256 electrodes; 4 mm spacing; 36cm2), and activation mapping was performed. Velocity fields were calculated using a finite difference approach incorporating a Gaussian filter smoothing function. Amplitudes were calculated using a peak-trough detection algorithm. Longitudinal and circumferential propagation data from corpus recordings were compared with Student's t-test. Means±SEM are reported. Results Atypical or dysrhythmic propagation was observed in 6/7 patients, including incomplete conduction block, complete block with escape, ectopic pacemaking in the corpus and antral tachygastria (freq range: 2.7-4.2 cpm). Circumferential propagation was associated with all of these events (circumferential velocity 6.6 ± 0.9 mm/s vs longitudinal velocity 2.9 ± 0.2 mm/s; p

Escherichia coli (O111:B4) and afterwards re-incubated for 24h in LPS-free culture medium (washout) to verify the persistency of muscular alterations. Reactive oxygen species (ROS), GSH content, mitochondrial membrane potential and apoptosis weremeasured by cytofluorometry; phospho-NF-KB p65 by ELISA and biological activity by scanning micrometry. Results are expressed as mean±SE and analysed by ANOVA, p