Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms.

PURPOSE: The purpose of this study was to use electromyography to examine the behavior of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation in patients with symptoms of obstructed defecation and in normal subjects to highlight differences of clinical significance. METHODS: A total of 35 patients (31 females) aged 20 to 80 (mean, 53.7 +/- 13.3) years with unprepared bowel who had normal colon transit time and obstructed defecation symptoms and 12 voluntary control subjects (7 females) aged 23 to 68 (mean, 48 +/- 11.5) years underwent an electromyography evaluation of the activity of the external sphincter, puborectalis muscle, and pubococcygeus muscle during attempted defecation. The patients were also examined in separate sessions with defecography and anal manometry. RESULTS: During attempted defecation, puborectalis muscle and external sphincter always reacted in the same manner. When evaluated with pubococcygeus muscle, three main patterns of activity were observed either in patients or in controls: 1) coordinated activation pattern; 2) coordinated inhibition pattern; and 3) uncoordinated or equivocal pattern: activation of pubococcygeus muscle with inhibition of puborectalis muscle/external sphincter, activation followed by inhibition of the three muscles, and activation followed by inhibition of pubococcygeus muscle and no change in the others. We never observed activation of puborectalis muscle/external sphincter concomitant with inhibition of pubococcygeus muscle. The inhibitory coordinated pattern occurred significantly (P = 0.01) more frequently in controls than in patients. These subjects also presented a significantly (P = 0.01) lower frequency of pubococcygeus muscle inhibition. CONCLUSIONS: Either activation or inhibition appears as a physiological behavior, possibly adopted in different circumstances, of the pelvic floor muscles during attempted defecation. The higher prevalence of coordinated inhibitory patterns in normal subjects and the lower frequency of pubococcygeus muscle inhibition in patients with symptoms of obstructed defecation, however, suggests that a loss of inhibition capacity progressing from pubococcygeus muscle to puborectalis muscle/external sphincter muscles could determine the insurgence of obstructed defecation symptoms in some subjects, who should therefore benefit from biofeedback retraining aimed at reacquisition of the inhibition capacity of all muscles of the pelvic floor during defecation.

Effects of chronic lithium treatment on the peripheral nervous system.

BACKGROUND: Although lithium carbonate is widely used in the treatment of mood disorders, symptoms suggesting toxic effects on the peripheral nervous system may emerge even in subjects whose serum lithium levels remain within the recommended therapeutic range. METHOD: Electroneuronographic (ENG) parameters (motor nerve conduction velocity of peroneal and median nerves, sensory nerve conduction velocity of sural and median nerves, amplitude of motor potential of peroneal and median nerves, and amplitude of sensory action potential of the median nerve at the wrist and the sural nerve) were investigated in 2 groups (N = 34) of patients suffering from bipolar affective disorder (DSM-III-R, DSM-IV) undergoing maintenance treatment with lithium carbonate for at least 1 year (mean = 2.06 years) in monotherapy. For 12 patients, ENG results were compared with pretreatment values, whereas in the other 22 cases, only data relevant to posttreatment were available. Fifty-four healthy subjects and 20 patients with recurrent major affective disorder (unipolar and bipolar) never treated with lithium made up the comparison groups. RESULTS: Compared with the 2 comparison groups, patients on chronic lithium treatment showed significant reduction of motor nerve conduction velocity of peroneal and median nerves, sensory nerve conduction velocity of sural and median nerves, amplitude of motor potential of peroneal and median nerves, and amplitude of sensory action potential of the median nerve at the wrist and the sural nerve. The comparison with the assessment made prior to lithium treatment also showed significant changes; after a period of treatment with lithium varying from 2 to 8 years (mean = 5.2 years), significant reductions were found on motor and sensory nerve conduction velocity and on amplitude motor potentials and sensory action potentials. CONCLUSION: Chronic maintenance treatment with lithium affects the peripheral nerves, even if the impairment rarely is such as to warrant discontinuation of treatment. Monitoring of ENG results could be useful for the early detection of neurotoxicity of lithium.

The ischaemia-hyperpnea test in the evaluation of neuronal hyperexcitability syndrome.

Electromyography (EMG) identifies abnormalities in the neuronal hyperexcitability syndrome (NHS) with high frequencies of false positive results. We examined 25 subjects with autonomic, psychic and neuromuscular symptoms of NHS. They underwent the ischaemia-hyperpnea test using stringent time criteria to study their symptoms as well as their electrolytical balance. The Kaplan-Meier analysis showed a significantly different incidence of repetitive discharges in the two groups in the post-ischaemic period (p < 0.004) and during hyperpnea (p < 0.001). The ischaemia-hyperpnea EMG test, when evaluated in relation to the the duration of activation procedure, was able to differentiate NHS patients from controls only within 4-6 minutes of ischaemia or hyperpnea. When restricted to this period, EMG observation with the triggering of Ischaemia-hyperpnea identified NHS with a high degree of sensitivity and specificity.

[Non-parasitic splenic cyst]. / Le cisti spleniche non parassitarie.

The Authors report a case of epithelial cyst of the spleen. The pathogenetic hypothesis as well as the clinical patterns of this rare disease, which is usually found in children and young adults, are considered.

Sporadic juvenile amyotrophic lateral sclerosis.

A case of sporadic amyotrophic lateral sclerosis with onset at 18 years of age and death one year after is reported. Only 8 other cases with such an early onset (and the typical clinical and pathological features of ALS) have been reported in the literature. Resemblances between these cases and adult ALS are pointed out, but since all knowledge about their etiology is lacking, the relationship between them remains unclear.

[Intestinal obstruction due to phytobezoars]. / L'occlusione intestinale da fitobezoari.

The authors report nine cases of small bowel obstruction due to phytobezoars, observed from January 1982 to October 1991. The main factors in the pathogenesis of phytobezoars, particularly alimentary habits and previous gastric surgery, are considered. In five patients the operation, always performed in emergency, consisted in a longitudinal enterotomy. In two cases the plasticity of the phytobezoar allowed for a manual progression beyond the ileocecal valve. In two patients an intestinal resection was necessary. The authors prefer the finger fracture technique with manual progression of the phytobezoar beyond the ileocecal valve when the ileal loop is well conserved and the phytobezoar itself has enough plasticity.

Electrophysiologic study of HIV-1 + patients without signs of peripheral neuropathy.

HIV-1 seropositive patients have a high frequency of nervous system diseases, and asymptomatic abnormalities are frequently detected. We studied 124 neurologically asymptomatic HIV-1 seropositive subjects and 23 normal control subjects by nerve conduction studies. No alterations were detectable in the asymptomatic stages of infection (CDC groups II and III), while subclinical peripheral nervous system (PNS) impairment was detected in symptomatic HIV-1 stages (CDC group IV). Specifically, in CDC group IV we observed a reduction in the motor conduction velocity of the deep peroneal nerve and the median nerve, and a similar reduction of the sensory conduction velocity of the sural nerve. There were no differences of the amplitude and area of the muscular response or of the sensory nerve action potential. As our patients did not present clinical or laboratory evidence for a toxic-dismetabolic etiology, our data indicate a progressive myelin damage more directly related to HIV-1 infection. This subclinical finding may have importance for the progression of the disease in the PNS.

[Percutaneous drainage of liver abscesses]. / Il drenaggio percutaneo degli ascessi epatici.

Three patients with hepatic abscess were treated by percutaneous drainage ultrasonographically or tomographically guided. The treatment was effective in two out of three patients. The low morbidity and the high success rate obtained suggest that this therapeutic modality should be used before considering any surgical approach.

[Intestinal obstruction caused by colorectal neoplasms]. / L'occlusione intestinale da neoplasia colo-rettale.

The Authors report their ten-year experience in 85 cases of colorectal carcinoma presenting with large bowel obstruction. They underline the high morbidity and mortality of such condition related to the late diagnosis and the poor general conditions of the patients. After reviewing the literature they point out that the best treatment consists in dealing both with the intestinal obstruction and its cause during the same operative time. The post-operative mortality after radical treatment is acceptable especially when compared to derivative procedures.

Lower cranial nerve palsy due to dissection of the internal carotid artery: CT and MR imaging.

Three patients with unilateral lower cranial nerve palsy underwent contrast enhanced CT and magnetic resonance (MR) imaging for the investigation of possible compressive pathology in the region of the jugular foramen. Computed tomography revealed a mural crescentic hypodensity of the corresponding internal carotid artery (ICA) in two patients and a faulty visualization of the vessel in one. Magnetic resonance revealed a corresponding hyperintense lesion expanding the wall and narrowing the lumen of the cervical ICA on both T1- and T2-weighted images. Dissection of the ICA was confirmed by angiography in all three patients. Among the possible etiologies of lower cranial nerve palsy, a dissecting hematoma of the cervical ICA must be considered, which can be diagnosed by CT and MR.

[Cancer of the gallbladder]. / II cancro della colecisti.

The Authors report their experience about 20 patients operated on since 1975 for primary carcinoma of the gallbladder. They remark their disappointment because of the poor percentage of preoperative and early diagnosis, that only allows a radical surgical therapy. More attention, therefore, should be payed to this not so rare pathology in the hope the survival of the patients radically operated will increase.

[Liver abscess: clinical cases and review of the literature]. / Gli ascessi epatici: casistica clinica e revisione della letteratura.

Personal experience with liver abscess is presented. After a review of the epidemiologic and aetiologic factors most commonly influencing hepatic abscesses formation, the Authors discuss their clinical and diagnostic aspects. Furthermore various surgical options are examined for the proper treatment of these conditions.

[Lithiasis of the common bile duct and transduodenal papillosphincterotomy. Analysis of our cases]. / Litiasi della via biliare principale e papillosfinterotomia transduodenale. Analisi della nostra casistica.

The results obtained from 1978 to 1987 with the use of transduodenal papillosphincterotomy in bile duct lithiasis are reported. The operation was performed on 126 patients and produced 4.7% immediate mortality. The indications and the most frequent post-operative complications were studied. Routine intra-operative cholangiography had been carried out. The long-term results were very good in 86% of the cases, average in 13% and poor in 1%. Provided one limits its indications to cases when it is really necessary, papillosphincterotomy does not involve a higher risk than other biliary operations.

Selective shunting based on somatosensory evoked potential monitoring during carotid endarterectomy.

Somatosensory Evoked Potentials (SEPs), to median nerve stimulation, were continuously monitored in 58 patients undergoing carotid endarterectomy A first group of patients was shunted routinely; in a second group the shunt was selectively applied when inadequacy of collateral circulation was suspected based on stump pressure values and SEP changes. Both amplitude and latency modifications of SEPs occurred during surgery; however no post-operative neurological deficit was seen unless there was a complete flattening of cortical waves, even a transitory one. Inadequate collateral circulation and embolic ischemia affected SEPs differently. While the latter produced a disappearance of all cortical waves, the former led first to a progressive flattening of later cortical waves and then of N20 as well. For values of stump pressure ranging between 20 and 50 mmHg SEPs were unchanged in some patients and altered in others. These findings may explain the controversies existing about the usefulness of stump pressure for predicting tolerance to carotid clamping.

Anorectal continence and bladder function. Effects of major sacral resection.

The effect of sacral resection up to S-2 has been investigated in two patients with "chordomas," surgical division of the spinal roots was unilateral and bilateral, respectively. Anal manometry, electromyography of the sphincters, and the ascertaining of tactile, thermic, and painful stimuli perception in the perineum and anal canal were executed to determine the effects of denervation on anorectal continence. Vesical function was tested by vesical manometry. Results differ strongly between the two patients: the first, with unilateral loss of S-2, has perfect anorectal continence. The second, with bilateral loss of S-2, is incontinent and unable to discriminate rectal contents. It is sufficient to retain only one S-2 root for the maintenance of physiologic continence, including distinction between different types of bowel contents (gaseous or solid) passing through the anal canal. The same is true concerning bladder function.

Plasma exchange in myasthenia gravis.

Results obtained with P.E. therapy on 19 myasthenic patients are reported. 15 of them improved during treatment and 4 remained unchanged. We believe P.E. is an useful therapy in M.G. because it produces a rapid improvement in most patients.

Plasma exchange in radiculopolyneuropathies.

The AA. report the results obtained with Plasma Exchange (P.E.) therapy on 24 cases of polyradiculoneuritis; eleven patients had typical Guillain-Barré Syndrome (G.B.S.) ten suffered from a chronic progressive form and three were affected by a relapsing form. The acute patients were selected according to criteria established by the NNCDS Committee (1978) while guidelines laid down by Pineas & Load (1978) were followed in choosing chronic cases. Patients with G.B.S. had four sessions of P.E. at intervals of one or two days while those with chronic forms of polyradiculoneuritis had a total of 6 sessions spaced one to three days apart. P.E. produced no apparent change in chronic progressive patients but two out of three cases with the chronic relapsing form showed rapid and steady improvement resulting in complete cure within a few months. Nine of the eleven G.B.S. patients showed after only one or two sessions a clear and rapid improvement which led to a complete cure within a matter of weeks. The remaining 2 cases showed only partial improvement at first and remained stationary thereafter. The findings confirm the usefulness of P.E. in acute and chronic relapsing radiculopolyneuritis. However, potential side effects and the procedure's high cost suggest that its use should be limited to carefully selected cases, and in particular to those involving respiratory disorders.