Sacral neuromodulation for fecal incontinence in Latin America: initial results of a multicenter study.

BACKGROUND: Sacral neuromodulation (SNM) is a widely used therapeutic option for fecal incontinence (FI). Larger series are mainly from Western countries, while few reports address the results of SNM in less developed or less wealthy countries. The aim of the present study was to evaluate the efficacy of SNM in patients with FI in Latin America. METHODS: A retrospective study was conducted on patients with FI who had SNM between 2009 and 2016 at 15 specialized colorectal surgery centers in Latin America. Main outcomes measures were functional outcomes, postoperative complications, requirement of revisional surgery, and requirement of device removal. All patients had failed conservative management and had clinical assessment including recording of the validated Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) and, when available, anal manometry and endoanal ultrasound. Patients were followed up for a median of 36.7 (1-84) months. RESULTS: One hundred and thirty-one patients [119 females, median age of 62.2 (range 19-87) years] were included. The most common etiology of FI was obstetric injury (n = 60; 45.8%). After successful test lead implantation, the stimulator was permanently placed in 129 patients (98.5%). One patient failed to respond in the test phase and one patient did not proceed to permanent implantation for insurance reasons. Nineteen patients (14.7%) had 19 complications including infection (n = 5, 3.8%), persistent implant site pain (n = 5, 3.8%), generator/lead dislodgment (n = 5, 3.8%), malfunctioning device (n = 3, 2.3%), and hematoma (n = 1, 0.7%). Reimplantation after the first and second stages was necessary in 2 (1.5%) and 3 patients (2.3%), respectively. The device removal rate was 2.2%. At a median follow-up of 36.7 (range 1-84) months, the CCF-FIS significantly improved from a preoperative baseline of 15.9 ± 2.98 to 5.2 ± 3.92 (95%CI: 15.46 vs 4.43; p < 0.0001). Overall, 90% of patients rated their improvement as "significant". CONCLUSIONS: Sacral nerve stimulation for FI is safe and efficient, even in less wealthy or less developed countries.

Anal sphincter injury after vaginal delivery in primiparous females.

PURPOSE: The purpose of this study was to determine the incidence of anal sphincter injury and fecal incontinence after vaginal delivery. METHODS: This was a prospective, descriptive, observational study conducted over a three-year period in healthy primiparous females with previously intact anal sphincter and normal continence and without history of anorectal surgery. All patients completed a continence questionnaire and underwent endoanal ultrasound four to six weeks before and six weeks after delivery. RESULTS: Ninety-eight primiparous females had either instrumental (vacuum or forceps) vaginal delivery (n = 23) or noninstrumental vaginal delivery (n = 75). Twenty patients, 11 (48 percent) after instrumental delivery and 9 (12 percent) after noninstrumental vaginal delivery, had clinical sphincter tears that required primary repair. Twenty-eight patients (29 percent), 19 with previously repaired sphincter injury, had ultrasonographic defects that involved the external sphincter (n = 19) or both the internal and external sphincter (n = 9). Twenty-one patients (75 percent) with ultrasonographic sphincter defects had either major (n = 5) or minor (n = 16) fecal incontinence. CONCLUSION: Anal sphincter injuries, many of them undiagnosed at the time of delivery, are common in primiparous females after vaginal delivery, especially if vacuum or forceps are used. These injuries cause fecal incontinence in a significant proportion of the patients. Patients undergoing vaginal delivery should be aware of the risks of anal sphincter injury.

Skeletal muscle adaptations in elastic resistance-trained young men and women.

Skeletal muscle adaptations (fiber-type composition, cross-sectional area, myosin heavy chain (MHC) content, and capillarity) were assessed in the vastus lateralis muscle of young men and women after 8 weeks of training with the Sportcord, an elastic resistance device. Ten men [mean (SD) age 20 (1.1) years] and 13 women [20 (1.2) years] performed two sets each to failure of single leg squats and leg extensions at approximately 50 repetitions x min(-1). Biopsy samples were taken from the right vastus lateralis muscle before and after training. Six fiber types (I, IC, IIC, IIA, IIAB, and IIB) were classified using myofibrillar ATPase histochemistry. Training with the Sportcord caused a small, but significant, increase in one-repetition maximum using free weights and a large increase in repetitions to failure. In addition, elastic resistance training caused an increase in the percentage of fibers classified as type IIAB for both men and women, and a decrease in the percentage of type IIB fibers in the men. MHC analysis supported these findings (a significant increase in the percentage of MHCIIa for the men). The cross-sectional areas ofboth the type I and IIAB + IIB fibers increased after training for the men, whereas no area changes were found for the women. The capillary:fiber ratio and capillary contacts per fiber type increased significantly for the men, and similar trends were noted for the women. Capillary density did not change in either the men or the women. These data suggest minor changes in fiber type composition (IIB-->IIAB), fiber size, and capillarization following short-term training with elastic resistance. Although muscular changes did occur using the Sportcord, the extent of these changes was less than those reported previously for short-term resistance-training programs using free weights.

Rehabilitation of the shoulder.

Rehabilitation of the shoulder has undergone significant changes during the past few years due to many clinical and basic science projects that have taught us about biomechanics of the shoulder. The athlete's shoulder is a particularly good model to allow us an understanding related to rehabilitation for treatment of injuries, injury prevention and performance enhancement. A comprehensive rehabilitation program for athletes can be based on these clinical and basic science principles to aid in our understanding of rehabilitation for shoulders in general.

Rehabilitation for the overhead athlete.

Rehabilitation of the shoulder of the overhead athlete has undergone significant changes during the past few years. This article illustrates shoulder problems related to repetitive overhead activities, such as throwing. Additionally, we present basic science contributions in this area, principles of shoulder rehabilitation, and a comprehensive rehabilitation program for the symptomatic or asymptomatic athlete based on these principles.

Training for Alpine skiing.

Skiing requires aerobic fitness. For aerobic conditioning, there must be significant elevation in heart rate during training. Although anaerobic training benefits physical fitness in general, skiing requires more aerobic than anaerobic conditioning. Strength, power, and endurance can be maintained through the use of concentric and eccentric contractions, using a variety of equipment and sports. Care should be taken to avoid injury to the patellofemoral joint during training. It is important to use specificity in choosing sports, as well as the exercise patterns in preseason training. If these principles are recognized in ski conditioning, a successful and effective training program will result.

Reversal of tricyclic-antidepressant-induced cardiac conduction abnormalities by phenytoin.

Ten patients with cardiac conduction defects due to severe tricyclic antidepressant poisoning were successfully treated with intravenous phenytoin. Eight patients had combined first degree AV block and intraventricular conduction delay; one patient had first degree AV block alone; and one patient had intraventricular conduction delay alone. Phenytoin was injected at a rate of 50 mg/min in amounts not exceeding 500 mg (approximately 5 mg/kg to 7 mg/kg). Five patients had complete normalization within 46 min. The remaining five patients showed improvement in their conduction defects shortly after phenytoin treatment, with complete normalization occurring within 14 hr. This investigation demonstrated the effectiveness of phenytoin in reversing tricyclic-antidepressant-induced cardiac conduction abnormalities. Phenytoin is a logical drug for the treatment of severe tricyclic antidepressant poisoning signalled by first degree AV block and/or intraventricular conduction delay.

Physiological Profiles of Elite Rowers.

Unlike distance runners, who set an aerobic pace, elite rowers quickly achieve extremely high energy expenditures, and therefore high lactate levels, which they must tolerate throughout the race.

Energy expenditure during simulated rowing.

Metabolic function was measured by open-circuit spirometry for 310 competitive oarsmen during and following a 6-min maximal rowing ergometer exercise. Aerobic and anaerobic energy contributions to exercise were estimated by calculating exercise O2 cost and O2 debt.O2 debt was measured for 30 min of recovery using oxygen consumption (Vo2) during light rowing as the base line. Venous blood lactates were analyzed at rest and at 5 and 30 min of recovery. Maximal ventilation volumes ranged from 175 to 22l 1/min while Vo2 max values averaged 5,950 ml/min and 67.6 ml/kg min. Maximal venous blood lactates ranged from 126 to 240 mg/100 ml. Average O2 debt equaled 13.4 liters. The total energy cost for simulated rowing was calculated at 221.5 kcal assuming 5 kcal/l O2 with aerobic metabolism contributing 70% to the total energy released and anaerobiosis providing the remaining 30%. Vo2 values for each minute of exercise reflect a severe steady state since oarsmen work at 96-98% of maximal aerobic capacity. O2 debt and lactate measurements attest to the severity of exercise and dominance of anaerobic metabolism during early stages of work.