Immediate effects of transcutaneous electrical nerve stimulation on gait patterns in chronic stroke survivors: A single group, pretest-posttest clinical trial.

BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) has been used to reduce muscle spasticity and improve locomotion in stroke survivors. We speculate that acute changes in gait performance after TENS mediate functional improvement in the long-term. However, no previous study has investigated the effect of TENS on ankle kinetics and kinematics during walking in stroke survivors. PURPOSE: We aimed to investigate whether TENS applied over the paretic leg could rapidly improve the plantar flexion moment and ankle kinematics in chronic stroke survivors with lower limb paresis. METHODS: Twenty chronic stroke survivors were recruited. They underwent 30 min of TENS over the area innervated by the common peroneal nerve on the paretic leg. Three-dimensional (3D) motion capture was performed and ankle plantar flexor spasticity was assessed before and immediately after stimulation. Ankle kinematics and kinetic and spatiotemporal data were collected using 3D motion capture. Ankle plantar flexor spasticity was assessed using the Modified Tardieu Scale. PRINCIPAL RESULTS: A significant increase in the ankle plantar flexion moment of the paretic side during the pre-swing phase was observed immediately after stimulation (p = 0.009, maximal mean difference = 0.035, 95%CI = 0.0125 to 0.0575). The step length of the paretic limb also increased significantly after stimulation (p = 0.023, mean difference = -0.02, 95%CI = -0.04 to -0.004). TENS had no immediate effect on paretic ankle spasticity, as measured by the Modified Tardieu Scale, or on other temporo-spatial parameters. CONCLUSION: The findings support the use of TENS to improve the motor function and gait pattern in chronic stroke survivors. The study indicated that the application of TENS to the paretic leg before gait training might improve rehabilitation outcomes. Future studies investigating the effects of TENS on functional outcomes, the optimal stimulation duration, and assessing spasticity using more sensitive measures are warranted.

Substance abuse effects on urinary tract: methamphetamine and ketamine.

INTRODUCTION: Ketamine is known to cause urinary tract dysfunction. Recently, methamphetamine (MA) abuse has become a growing problem in Asia. We investigated the symptomatology and voiding function in patients who abused MA and ketamine and compared their urinary tract toxicity profiles. METHODS: In the period of 23 months from 1 October 2016, all consecutive new cases of patients presenting with MA- or ketamine-related urological disorder were recruited into a prospective cohort. Polysubstance abuse patients were excluded. Data were analysed by comparison between patients with ketamine abuse and MA abuse. Basic demographic data and initial symptomatology were recorded, and questionnaires on urinary symptoms and the Montreal Cognitive Assessment (MoCA) were used as assessment tools. RESULTS: Thirty-eight patients were included for analysis. There was a statistically significant difference in mean age between patients with MA and ketamine abuse (27.2 ± 7.2 years and 31.6 ± 4.8 years, respectively, P=0.011). Urinary frequency was the most common urological symptom in our cohort of patients. There was a significant difference in the prevalence of dysuria (ketamine 43.5%, MA 6.7%, P=0.026) and a significant trend in the difference in hesitancy (ketamine 4.3%, MA 26.7%, P=0.069). Overall, questionnaires assessing urinary storage symptoms and voiding symptoms did not find a statistically significant difference between the two groups. The MoCA revealed that both groups had cognitive impairment (ketamine 24.8 ± 2.5, MA 23.6 ± 2.9, P=0.298). CONCLUCSIONS. Abuse of MA caused urinary tract dysfunction, predominantly storage symptoms. Compared with ketamine abuse, MA abuse was not commonly associated with dysuria or pelvic pain.

Proposal of a new classification system for complete mesocolic excison in right-sided colon cancer.

BACKGROUND: Although complete mesocolic excision has been performed for 10 years there remains no published prospective data. The lack of a classification which includes completeness of mesocolic tissue removal as well as plane of surgery contributes to the problem of comparing studies. The aim of the present study was to develop such a classification for right hemicolectomy. METHODS: In a prospective, non-randomized trial we collected specimens of right hemicolectomies from 38 German hospitals between February 2012 and October 2016. The degree of radicality of resection was reported. Photographs were taken of the specimens. After screening the images it became apparent that the specimens could be divided into four main groups according to the degree of missing mesocolic tissue, and three subgroups reflecting the plane of surgery. RESULTS: Of 1373 patients 1097 images were available. Grading was possible in 1077 (98.2%). Distribution was Type 0 (best) 38.6%, Type I 43.3%, Type II 8.5%, Type III (poorest) 7.8%. Surgery was considered to be in a suboptimal plane of surgery in 15.2% overall, highest in Type III (37%) and lowest in Type 0 (7.8%, p < 0.001). CONCLUSIONS: The proposed classification may be a relevant tool for the further investigation of CME for right colon cancer because it allows us to differentiate the aspects of lymphadenectomy and the preservation of the integrity of the mesocolon.

Hypospadias surgery in children: improved service model of enhanced recovery pathway and dedicated surgical team.

INTRODUCTION: Children in Hong Kong are generally hospitalised for 1 to 2 weeks after hypospadias repairs. In July 2013, we introduced a new service model that featured an enhanced recovery pathway and a dedicated surgical team responsible for all perioperative services. In this study, we investigated the outcomes of hypospadias repair after the introduction of the new service model. METHODS: We conducted a retrospective study on consecutive children who underwent primary hypospadias repair from January 2006 to August 2016, comparing patients under the old service with those under the new service. Outcome measures included early morbidity, operative success, and completion of enhanced recovery pathway. RESULTS: The old service and new service cohorts comprised 176 and 126 cases, respectively. There was no difference between the two cohorts in types of hypospadias and surgical procedures performed. The median hospital stay was 2 days in the new service cohort compared with 10 days in the old service cohort (P<0.001). Patients experienced less early morbidity (5.6% vs 15.9%; P=0.006) and had a lower operative failure rate (20.2% vs 44.2%; P<0.001) under the new service than the old service. Multivariable analysis revealed that the new service significantly reduced the odds of early morbidity (odds ratio=0.35, 95% confidence interval=0.15-0.85; P=0.02) and operative failure (odds ratio=0.32, 95% confidence interval=0.17-0.59; P<0.001) in comparison with the old service. Of the new service cohort, 111(88.1%) patients successfully completed the enhanced recovery pathway. CONCLUSIONS: The enhanced recovery pathway can be implemented safely and effectively to primary hypospadias repair. A dedicated surgical team may play an important role in successful implementation of the enhanced recovery pathway and optimisation of surgical outcomes.

Management of complications of ketamine abuse: 10 years' experience in Hong Kong.

Ketamine is an N-methyl-d-aspartate receptor antagonist, a dissociative anaesthetic agent and a treatment option for major depression, treatment-resistant depression, and bipolar disorder. Its strong psychostimulant properties and easy absorption make it a favourable candidate for substance abuse. Ketamine entered Hong Kong as a club drug in 2000 and the first local report of ketamine-associated urinary cystitis was published in 2007. Ketamine-associated lower-urinary tract symptoms include frequency, urgency, nocturia, dysuria, urge incontinence, and occasionally painful haematuria. The exact prevalence of ketamine-associated urinary cystitis is difficult to assess because the abuse itself and many of the associated symptoms often go unnoticed until a very late stage. Additionally, upper-urinary tract pathology, such as hydronephrosis, and other complications involving neuropsychiatric, hepatobiliary, and gastrointestinal systems have also been reported. Gradual improvement can be expected after abstinence from ketamine use. Sustained abstinence is the key to recovery, as relapse usually leads to recurrence of symptoms. Both medical and surgical management can be used. The Youth Urological Treatment Centre at the Prince of Wales Hospital, Hong Kong, has developed a four-tier treatment protocol with initial non-invasive investigation and management for these patients. Multidisciplinary care is essential given the complex and diverse psychological factors and sociological background that underlie ketamine abuse and abstinence status.

Clinical heterogeneity in children with gonadal dysgenesis associated with non-mosaic 46,XY karyotype.

INTRODUCTION: Gonadal dysgenesis is unique in disorders of sex development (DSD), in that it can be associated with 46,XX, 46,XY or mosaic 45,X/46,XY karyotypes. Gonadal dysgenesis can be partial or complete. Gonadal dysgenesis associated with the Y-chromosome has increased risk of gonadal germ cell neoplasms. Most of the literature focus on 45,X/46,XY gonadal dysgenesis, while there are scanty data on the condition when the karyotype is non-mosaic 46,XY. OBJECTIVE: To investigate the diversity of clinical pictures of children presenting with 46,XY DSD due to gonadal dysgenesis. METHODS: A retrospective study on consecutive patients diagnosed with 46,XY gonadal dysgenesis at age ≤18 years in a tertiary center from 1985 to 2015. The clinical presentations, phenotypes, gonadal features and associated anomalies were investigated. RESULTS: Twenty-eight patients with Y-chromosome gonadal dysgenesis were identified during the study period and six (21.4%) had non-mosaic 46,XY karyotype. Three had complete gonadal dysgenesis (CGD) with normal female phenotype, while the other three had partial gonadal dysgenesis (PGD). Of the three patients with CGD, two presented with the classical Swyer syndrome at adolescence, while the third presented at birth with multiple congenital anomalies. The three PGD patients presented with ambiguous genitalia at birth (n = 2), and isolated hypospadias (n = 1), which was associated with Frasier syndrome. Three patients had germ cell neoplasms: bilateral gonadoblastoma (n = 1), bilateral intratubular germ cell neoplasia unclassified (n = 1), and dysgerminoma + gonadoblastoma (n = 1). Two patients had global developmental delay with other congenital anomalies, and another patient had learning difficulties with borderline intelligence (Table). DISCUSSION: The findings suggest that 46,XY gonadal dysgenesis is much rarer than 45,X/46,XY gonadal dysgenesis. Patients differed in their clinical presentations and well-established syndromes happened in half of them. Overall, the risk of germ cell neoplasms and the association with other somatic anomalies appeared to be high. The study was limited by: its small number, single-center experience, and the possibility of missing the diagnosis in some male patients with mild undervirilization. CONCLUSION: Heterogeneity was noted in the clinical, phenotypic and gonadal features among pediatric patients with 46,XY gonadal dysgenesis.

Population-based survey of the prevalence of lower urinary tract symptoms in adolescents with and without psychotropic substance abuse.

OBJECTIVE: To investigate the prevalence of lower urinary tract symptoms in adolescents and the effects of psychotropic substance use. METHODS: This was a population-based cross-sectional survey using a validated questionnaire in students from 45 secondary schools in Hong Kong randomly selected over the period of January 2012 to January 2014. A total of 11 938 secondary school students (response rate, 74.6%) completed and returned a questionnaire that was eligible for analysis. Individual lower urinary tract symptoms and history of psychotropic substance abuse were documented. RESULTS: In this study, 11 617 non-substance abusers were regarded as control subjects and 321 (2.7%) were psychotropic substance users. Among the control subjects, 2106 (18.5%) had experienced at least one lower urinary tract symptom with urinary frequency being the most prevalent symptom (10.2%). Females had more daytime urinary incontinence (P<0.001) and males had more voiding symptoms (P=0.01). Prevalence of lower urinary tract symptoms increased with age from 13.9% to 25.8% towards young adulthood and age of ≥18 years (P<0.001). Among the substance users, ketamine was most commonly abused. Substance users had significantly more lower urinary tract symptoms than control subjects (P<0.001). In multivariate analysis, increasing age and psychotropic substance abuse increased the odds for lower urinary tract symptoms. Non-ketamine substance users and ketamine users were respectively 2.8-fold (95% confidence interval, 2.0-3.9) and 6.2-fold (4.1-9.1) more likely than control subjects to develop lower urinary tract symptoms. Females (odds ratio=9.9; 95% confidence interval, 5.4-18.2) were more likely to develop lower urinary tract symptoms than males (4.2; 2.5-7.1) when ketamine was abused. CONCLUSIONS: Lower urinary tract symptoms are prevalent in the general adolescent population. It is important to obtain an accurate history regarding psychotropic substance use when treating teenagers with lower urinary tract symptoms.

Tratamiento láser de los tumores primarios endobronquiales benignos / No disponible

Objetivo: Estudio descriptivo de pacientes del Hospital Universitario de La Princesa con diagnóstico de tumoración endobronquial benigna. Material y métodos: Se analizan las características de pacientes del Servicio de Cirugía Torácica del Hospital Universitario de La Princesa desde el año 2002 a 2012. Resultados: Presentamos 9 casos diagnosticados, 8 de ellos tratados mediante broncoscopia láser y uno mediante cirugía abierta. El láser fue aplicado a través de broncoscopia flexible y broncoscopia rígida. La mayoría fueron tratados con una única sesión, siendo dados de alta el mismo día del procedimiento sin complicaciones. A los 2 años de seguimiento se objetiva una remisión del 100%. Conclusiones: Consideramos que el tratamiento deber ser individualizado, teniendo en cuenta como terapia de primera línea la aplicación de láser endoscópico

Aims: A descriptive study of patients of the La Princesa University Hospital diagnosed with benign endobronchial tumor. Material and methods: The characteristics of patients admitted to the La Princesa University Hospital - Thoracic Surgery Unit during 2002-2012 were analyzed. Results: We present 9 diagnosed cases, 8 of them treated by laser bronchoscopy and one open surgery. The laser was applied via flexible bronchoscopy, rigid bronchoscopy. Most were treated with one session being discharged the same day of the procedure without complications. At 2 years of follow remission of 100% objective. Conclusions: We believe that treatment should be individualized, taking into account as first-line therapy application of endoscopic laser

Core Muscle Activity during TRX Suspension Exercises with and without Kinesiology Taping in Adults with Chronic Low Back Pain: Implications for Rehabilitation.

This study aimed to examine the effects of kinesiology taping (KT) and different TRX suspension workouts on the amplitude of electromyographic (EMG) activity in the core muscles among people with chronic low back pain (LBP). Each participant (total n = 21) was exposed to two KT conditions: no taping and taping, while performing four TRX suspension exercises: (1) hamstring curl, (2) hip abduction in plank, (3) chest press, and (4) 45-degree row. Right transversus abdominis/internal oblique (TrAIO), rectus abdominis (RA), external oblique (EO), and superficial lumbar multifidus (LMF) activity was recorded with surface EMG and expressed as a percentage of the EMG amplitude recorded during a maximal voluntary isometric contraction of the respective muscles. Hip abduction in plank increased TrAIO, RA, and LMF EMG amplitude compared with other TRX positions (P < 0.008). Only the hamstring curl was effective in inducing a high EMG amplitude of LMF (P < 0.001). No significant difference in EMG magnitude was found between the taping and no taping conditions overall (P > 0.05). Hip abduction in plank most effectively activated abdominal muscles, whereas the hamstring curl most effectively activated the paraspinal muscles. Applying KT conferred no immediate benefits in improving the core muscle activation during TRX training in adults with chronic LBP.

[Complete Mesocolic Excision for Right-Sided Colon Cancer - The Role of Central Lymph Nodes]. / Die komplette mesokolische Exzision beim rechtsseitigen Kolonkarzinom - welche Rolle spielen die zentralen Lymphknoten?

BACKGROUND: Complete mesocolic excision (CME) and central vascular ligation (CVL) for right-sided colon cancer may be superior to standard hemicolectomy in terms of oncological results. This hypothesis is currently being investigated in a large multicentre trial conducted by the authors of this paper (Resektatstudie). Because CVL in right-sided hemicolectomy is technically rather demanding the incidence of central node involvement is of special interest. Therefore, during the single centre pilot phase of our multicentre trial we have analysed the incidence of central lymph node metastasis in CME specimens. PATIENTS: In 51 patients with right-sided colon adenocarcinoma (cT1-3, cM0) an open CME with CVL was performed. In the fresh specimen the central four centimetres of the ileocolic vessels that would have been presumably left in place during a standard hemicolectomy were marked with a suture. The lymph nodes in this segment were separately analysed. RESULTS: In the CME specimen the mean lymph node count was 52.6 (range: 27-171). 35.0 % (range: 13.1-65.6 %) of the nodes were located in the central 4 cm segment. The proportion of patients with positive nodes was 25.5 % (13/51). Of all nodes 1.97 % (53/2686) were metastatic. In 3/51 (5.8 %) patients the central nodes were involved. In one patient the central nodes were the only metastatic site. UICC stage was influenced in two of the three patients who had central involvement (stage migration: UICC IIB to IIIB, UICC IIIB to IIIC). CONCLUSION: CME with CVL in right-sided colon adenocarcinoma increases the probability of complete removal of the local lymph node drainage and thus local metastatic lymph nodes. Considering this result an improvement of long-term survival by the CME procedure seems conceivable but needs to be confirmed by the current multicentre trial.

Reconstructive surgery for females with congenital adrenal hyperplasia due to 21-hydroxylase deficiency: a review from the Prince of Wales Hospital.

OBJECTIVES: To present the results of feminising genitoplasty done in female patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. DESIGN: Case series. SETTING: A tertiary referral centre in Hong Kong. PATIENTS: Female patients with congenital adrenal hyperplasia undergoing corrective surgery for virilisation between 1993 and 2012. MAIN OUTCOME MEASURES: The operative result was judged with a scoring system (1-3) for four areas: appearance of clitoris, labia and vagina, plus requirement for revision surgery. RESULTS: A total of 23 female patients with congenital adrenal hyperplasia with a median age of 17.5 (range, 1.5-33.8) years were identified. Of these individuals, 17 presented in the neonatal period and early infancy, of which four had an additional salt-losing crisis. Six patients-including four migrants from mainland China-were late presenters at a median age of 2 (range, 0.5-14) years. Twenty-two patients had corrective surgery at a median age of 2 (range, 1-14) years. Clitoral reduction was performed in all, and further surgery in 21 patients. The additional surgery was flap vaginoplasty in 10 patients, a modified Passerini procedure in six, and a labial reconstruction in five; one patient with prominent clitoris was for observation only. Minor revision surgery (eg mucosal trimming) was required in three patients; a revision vaginoplasty was done in one individual. Of the 23 patients, 18 (78%) with a median age of 20 (range, 9.3-33.8) years participated in the outcome evaluation: a 'good' outcome (4 points) was seen in 12 patients and a 'satisfactory' (5-9 points) result in five patients. CONCLUSIONS: Nearly three quarters of our cohort (n=17) presented with classic virilising form of 21-hydroxylase deficiency. Only four (25%) patients experienced a salt-losing crisis. Female gender assignment at birth was maintained for all individuals in this group. 'Good' and 'satisfactory' outcomes of surgery were reported in nearly all participants.

Cochlear implant programming: a global survey on the state of the art.

The programming of CIs is essential for good performance. However, no Good Clinical Practice guidelines exist. This paper reports on the results of an inventory of the current practice worldwide. A questionnaire was distributed to 47 CI centers. They follow 47600 recipients in 17 countries and 5 continents. The results were discussed during a debate. Sixty-two percent of the results were verified through individual interviews during the following months. Most centers (72%) participated in a cross-sectional study logging 5 consecutive fitting sessions in 5 different recipients. Data indicate that general practice starts with a single switch-on session, followed by three monthly sessions, three quarterly sessions, and then annual sessions, all containing one hour of programming and testing. The main focus lies on setting maximum and, to a lesser extent, minimum current levels per electrode. These levels are often determined on a few electrodes and then extrapolated. They are mainly based on subjective loudness perception by the CI user and, to a lesser extent, on pure tone and speech audiometry. Objective measures play a small role as indication of the global MAP profile. Other MAP parameters are rarely modified. Measurable targets are only defined for pure tone audiometry. Huge variation exists between centers on all aspects of the fitting practice.

Clinical analysis of submucosal Medpor implantation for empty nose syndrome.

BACKGROUND: Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates.The treatment of ENS is still debatable. PURPOSE: To analyse clinical outcomes of submucosal Medpor® implantation for ENS. METHODS: A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients' symptoms before and after surgery. RESULTS: Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively. CONCLUSIONS: The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.

Hitching the gallbladder in laparoscopic-assisted cholecysto-cholangiography: a simple technique.

Neonatal cholestatic disorder in the late neonatal period requires often cholangiography to differentiate between biliary atresia and other causes of prolonged neonatal jaundice. A simplified method of a laparoscopic-assisted cholecysto-cholangiography is presented. Retrospective chart review was conducted of all patients who from May 2002 to April 2012 underwent a laparoscopic-assisted cholecysto-cholangiography with routine fixation of the fundus of the gallbladder to the lateral aspect of the abdominal wall. A total of 18 infants (8 boys) aged 41-104 (median 64) days underwent laparoscopic-assisted cholecysto-cholangiography for prolonged jaundice. The technique identified ten cases of a patent bile duct system and eight biliary atresias. (Thirty-two cases of suspected biliary atresia were confirmed by laparoscopy alone.) Two cases required suturing of a bile leak at the puncture site. Hitching the gallbladder to the lateral abdominal wall is a simple method allowing an optimal radiographic assessment of the extra- and intra-hepatic bile duct anatomy.

Randomized comparison of closed-loop feedback computer-controlled with manual-controlled infusion of phenylephrine for maintaining arterial pressure during spinal anaesthesia for caesarean delivery.

BACKGROUND: Closed-loop feedback computer-controlled infusion has not been described for administering phenylephrine to maintain arterial pressure (AP) during spinal anaesthesia for caesarean delivery. We aimed to compare AP control using this automated system with a previously described manual infusion system. METHODS: We randomly allocated 222 healthy subjects having spinal anaesthesia for scheduled caesarean delivery to have systolic AP maintained near baseline with phenylephrine (100 µg ml(-1)) by computer-controlled infusion utilizing a proportional algorithm or manual-controlled infusion utilizing an on-off algorithm. AP control was assessed by comparing the proportion of systolic AP measurements within ±20% of baseline and by performance error (PE) calculations. RESULTS: A total of 212 subjects finished the study. In the computer-control group, 97% of systolic AP recordings fell within ±20% of baseline compared with 95% in the manual-control group (P=0.0004). For computer-control compared with manual-control, wobble was smaller [median 3.5 (inter-quartile range 2.5-4.8)% vs 4.2 (3.3-5.9)%, P=0.003], but there was no difference in the median PE [2.9 (0.3-4.7)% vs 1.9 (0-4.2)%], median absolute PE [4.7 (3.5-5.6)% vs 4.7 (3.8-6.7)%], or divergence [-0.01 (-0.03-0)% vs -0.06 (-0.26-0.08)%]. Fewer interventions per subject for controlling AP were required in the computer-control group [2 (2-2) vs 10 (8-13), P<0.001]. There were no differences in measured clinical outcomes. CONCLUSIONS: Within the constraints of the studied algorithms, closed-loop feedback computer-controlled phenylephrine infusion provided better AP control with fewer interventions required compared with manual-controlled infusion.

Hypertrophic pyloric stenosis in a newborn: a diagnostic dilemma.

Infants with hypertrophic pyloric stenosis typically present at 2 to 4 weeks of age with nonbilious projectile vomiting. Hypertrophic pyloric stenosis is exceedingly rare in newborn infants and is scarcely reported in literature. Also, the diagnostic criteria for ultrasonographic measurements in newborn infants have yet to be determined. This report is of a newborn infant with hypertrophic pyloric stenosis. The patient presented with high-volume non-bile-stained output from a nasogastric tube and a dilated gastric bubble on abdominal radiograph. Contrast study ruled out intestinal malrotation. Two ultrasound tests showed that the pyloric muscle thickness and pyloric canal length were within normal limits. Subsequent laparotomy showed a thickened pylorus and pyloromyotomy was performed. The patient showed marked improvement in feeding postoperatively. A high index of suspicion is required for newborn infants presenting with gastric outlet obstruction. Ultrasound and contrast studies provide additional information, but definitive diagnosis may only be available intra-operatively.