Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients.

BACKGROUND: Evacuatory dysfunction (ED) is a common cause of constipation and may be sub-classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for 'functional' defecatory disorders (FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED. METHODS: One hundred consecutive patients fulfilling Rome III criteria for functional constipation underwent four tests: expulsion of a rectal balloon distended to 50 mL (BE50 ) or until patients experienced the desire to defecate (BEDDV ), evacuation proctography (EP) and anorectal manometry. Yields and agreements between tests for the diagnosis of ED and FDD were assessed. KEY RESULTS: Positive diagnostic yields for ED were: BEDDV 18%, BE50 31%, EP 38% and anorectal manometry (ARM) 68%. Agreement was substantial between the two balloon tests (k = 0.66), only fair between proctography and BE50 (k = 0.27), poor between manometry and proctography (k = 0.01), and there was no agreement between the balloon tests and manometry (k = -0.07 for both BE50 and BEDDV ). For the diagnosis of FDD, there was only fair agreement between ARM and EP (k = 0.23), ARM ± BE50 and EP (k = 0.18), ARM and EP ± BE50 (k = 0.30) and ARM ± BE50 and EP ± BE50 (k = 0.23). CONCLUSIONS & INFERENCES: There is considerable disagreement between the results of various tests used to diagnose ED and FDD. This highlights the need for a reappraisal of both diagnostic criteria, and what represents the 'gold standard' investigation.

A double-blinded randomized multicentre study to investigate the effect of changes in stimulation parameters on sacral nerve stimulation for constipation.

AIM: Sacral nerve stimulation (SNS) may be offered to patients with constipation who have failed to improve with conservative treatment. The response to SNS is variable, with a significant loss of efficacy in some patients. An increased frequency of stimulation may improve the efficacy of SNS for faecal incontinence. This study aimed to see if alteration of the pulse width or frequency improved the outcome for those with constipation. METHOD: Eleven patients with constipation currently being treated by SNS were recruited from three centres. They were randomized to five different protocols of stimulation each applied for 5 weeks. Group 1 used standard settings (pulse width 210 µs, frequency 14 Hz); in the other four groups (Groups 2-5) the pulse width and/or frequency were halved or doubled. Patients and investigators were blinded to the group allocation. RESULTS: The Cleveland Clinic constipation score varied significantly between the five groups. Group 1 achieved the lowest score mean (± SD) 13.4 (± 4.4) (P = 0.03). The number of digitations per defaecation was the lowest in Group 4, 90 µs and 14 Hz (P < 0.01). No other variable changed significantly. Standard settings were the most preferred by the recruited patients. CONCLUSION: Alteration of pulse width or frequency of stimulation had no significant effect on the outcome of SNS for constipation.

Randomized clinical trial of sacral versus percutaneous tibial nerve stimulation in patients with faecal incontinence.

BACKGROUND: Sacral nerve stimulation (SNS) is a well established therapy for faecal incontinence (FI). Percutaneous tibial nerve stimulation (PTNS) is a newer, less invasive, treatment. The effectiveness and acceptability of these treatments have not been compared systematically. METHODS: An investigator-blinded randomized pilot trial of PTNS versus SNS with a parallel qualitative study was performed. Quantitative clinical outcomes and qualitative data from patient interviews were collected for both interventions. RESULTS: Forty patients (39 women; mean age 59 years) met the eligibility criteria; 23 were randomized to receive SNS and 17 to PTNS. Fifteen patients progressed to permanent SNS implantation and 16 received a full course of PTNS. Within-group effect sizes were marginally greater for SNS than for PTNS on available-case analysis. Mean(s.d.) FI episodes per week at baseline, and 3 and 6 months of follow-up were: 11·4(12·0), 4·0(4·0) and 4·9(6·9) respectively for SNS compared with 10·6(11·2), 5·8(6·9) and 6·3(6·9) for PTNS. Mean(s.d.) Cleveland Clinic Incontinence Score values at baseline, and 3 and 6 months were: 16·2(3·0), 11·1(5·2) and 10·4(5·6) for SNS versus 15·1(2·7), 11·7(4·4) and 12·1(5·2) for PTNS. Improvement of at least 50 per cent in FI episodes per week at 6 months was seen in 11 of 18 patients in the SNS group compared with seven of 15 in the PTNS group. Effect estimates for SNS with chronic implanted stimulation were larger (10 of 15 patients at 6 months). Disease-specific and generic quality-of-life improvements complemented clinical outcome data. Qualitative analysis of interview data suggested that both treatments had high acceptability amongst patients. CONCLUSION: In the short term, both SNS and PTNS provide some clinical benefit to patients with FI. Registration numbers: 2010-018728-15 and 10479 (http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=10479).

Systematic review of tibial nerve stimulation to treat faecal incontinence.

BACKGROUND: Two forms of tibial nerve stimulation are used to treat faecal incontinence (FI): percutaneous (PTNS) and transcutaneous (TTNS) tibial nerve stimulation. This article critically appraises the literature on both procedures. METHODS: A systematic review was performed adhering to the PRISMA framework. A comprehensive literature search was conducted, with systematic methodological quality assessment and data extraction. Summary measures for individual outcome variables are reported. RESULTS: Twelve articles met eligibility criteria; six related to PTNS, five to TTNS, and one to both procedures. These included ten case series and two randomized clinical trials (RCTs). Case series were evaluated using the National Institute for Health and Care Excellence quality assessment for case series, scoring 3-6 of 8. RCTs were evaluated using the Jadad score, scoring 4 of a possible 5 marks, and the Cochrane Collaboration bias assessment tool. From one RCT and case series reports, the success rate of PTNS, based on the proportion of patients who achieved a reduction in weekly FI episodes of at least 50 per cent, was 63-82 per cent, and that of TTNS was 0-45 per cent. In an RCT of TTNS versus sham, no patient had a reduction in weekly FI episodes of 50 per cent or more, whereas in an RCT of PTNS versus TTNS versus sham, 82 per cent of patients undergoing PTNS, 45 per cent of those having TTNS, and 13 per cent of patients in the sham group had treatment success. CONCLUSION: PTNS and TTNS result in significant improvements in some outcome measures; however, TTNS was not superior to sham stimulation in a large, adequately powered, RCT. As no adequate RCT of PTNS versus sham has been conducted, conclusions cannot be drawn regarding this treatment.

Systematic review of the clinical effectiveness of neuromodulation in the treatment of faecal incontinence.

BACKGROUND: Over the past 18 years neuromodulation therapies have gained support as treatments for faecal incontinence (FI); sacral nerve stimulation (SNS) is the most established of these. A systematic review was performed of current evidence regarding the clinical effectiveness of neuromodulation treatments for FI. METHODS: The review adhered to the PRISMA framework. A comprehensive search of the literature included PubMed, MEDLINE, Embase and Evidence-Based Medicine Reviews. Methodological quality assessment and data extraction were completed in a systematic fashion. RESULTS: For SNS, 321 citations were identified initially, of which 61 studies were eligible for inclusion. Of studies on other neuromodulation techniques, 11 were eligible for review: seven on percutaneous tibial nerve stimulation (PTNS) and four on transcutaneous tibial nerve stimulation (TTNS). On intention-to-treat, the median (range) success rates for SNS were 63 (33-66), 58 (52-81) and 54 (50-58) per cent in the short, medium and long terms respectively. The success rate for PTNS was 59 per cent at the longest reported follow-up of 12 months. SNS, PTNS and TTNS techniques also resulted in improvements in Cleveland Clinic Incontinence Score and quality-of-life measures. Despite significant use of neuromodulation in treatment of FI, there is still no consensus on outcome reporting in terms of measures used, aetiologies assessed, length of follow-up or assessment standards. CONCLUSION: Emerging data for SNS suggest maintenance of its initial therapeutic effect into the long term. The clinical effectiveness of PTNS is comparable to that of SNS at 12 months, although there is no evidence to support its continued effectiveness after this period. PTNS may be a useful treatment before SNS. The clinical effectiveness of TTNS is still uncertain owing to the paucity of available evidence. A consensus to standardize the use of outcome measures is recommended in order that further reports can be compared meaningfully.

An audit and comparative analysis of the kidney transplantation programme in Burma.

BACKGROUND: The first renal transplant operation to be carried out by a Burmese transplant team was undertaken at the Yangon General Hospital, Burma on the 8th of May 1997. Since then 21 further kidney transplantations have been performed in hospitals in Yangon (Rangoon) and Mandalay. Burma was renamed as Myanmar in 1989. The Myanmar national renal transplant programme was introduced and performed as a special project organised by the Ministry of Health. Unfortunately little is known in other countries about the programme's development or the outcomes of the patients treated. OBJECTIVES: In August 2003, the author visited Myanmar with the intention of evaluating the progress that this programme had made in the last six years. MATERIAL AND METHODS: Retrospective data concerning all recipients and donors involved in the Myanmar renal transplant programme was obtained from the patient databases and through personal meetings with staff at the Urology and Nephrology units in Yangon and Mandalay. RESULTS: All 22 cases were blood related living donor transplants. There were 14 males and 8 female donors with a mean age of 36.5 (28-53) years and 13 male and 9 female recipients with a mean age of 38.3 (19-60) years included in the programme. There was a 100% survival rate of all 22 donors and a 95% (n = 21) recipient survival rate recorded in the programme up to September 2003. The one-year graft survival rate is 95% (n = 21) and the overall graft survival rate until September 2003 is 91% (n = 20), the mean follow-up was 2 years and 4 months. CONCLUSION: The success of this programme is extremely impressive considering the turbulent socio-economic climate in this developing country. The next steps for Myanmar are to organise a domestic registry system for transplants, the organisation of personnel to take responsibility for data collection, distribution and greater communication with other transplant units.

A tale of 2 cities: a comparison of demographic details, source of referral, spectrum of infection and contraceptive practice in patients under 16 years attending genitourinary medicine clinics in London and Swansea.

Sexually transmitted infections (STIs) in young people are increasing, with children aged less than 16 years being particularly vulnerable. We compared the demographic details, spectrum of infection, contraceptive practice and source of referral in patients aged less than 16 years attending 2 genitourinary clinics, one in Swansea and the other in London. In the London population, children aged less than 16 years represented 0.7% of the total new attendances compared with 1.4% in Swansea. The female to male ratio was almost 4:1 in both clinics with most infections confined to female attenders. In females the incidence of chlamydial infection, genital warts and anaerobic (bacterial) vaginosis was 5.5%, 19% and 8%, respectively in London compared with 27%, 32% and 36% in Swansea. Seventy-two per cent of patients attending the clinic in London were self referred compared with 40% in Swansea. Contraceptive practice was also markedly different in the 2 populations, and over one-third of children in both clinics used no contraception. The high incidence of STIs in both populations and low use of contraception has serious implications for the sexual health of young people and emphasizes the need for effective sexual health education at an early age.

Comparison of risk factors for four sexually transmitted infections: results from a study of attenders at three genitourinary medicine clinics in England.

OBJECTIVE: To compare the risk factors for four common sexually transmitted infections (STIs) in attenders at three large urban genitourinary medicine (GUM) clinics in England. METHODS: Clinical, demographic, and behavioural data on attenders at two clinics in London and one in Sheffield were collected. Risk factors associated with first episodes of genital warts and genital herpes simplex virus (HSV), and uncomplicated gonorrhoea and chlamydia were investigated using the presence of each of these STIs as the outcome variable in separate multiple logistic regression analyses. RESULTS: Using data on the first attendance of the 18,238 patients attending the clinics in 1996, the risk of a gonorrhoea or chlamydia diagnosis was strongly associated with teenagers compared with those aged over 34, with black Caribbeans and black Africans compared with whites, and increased with the number of sexual partners. The risk of genital warts or HSV diagnosis was lowest in black Caribbeans and black Africans compared with whites and was not associated with the number of sexual partners. While genital warts were associated with younger age, odds ratios were much lower compared with those for the bacterial infections. Genital HSV diagnoses were not associated with age. CONCLUSIONS: This study of GUM clinic attenders suggests a reduction in the incidence of bacterial STIs may be achievable through targeted sexual health promotion focusing particularly on black ethnic minorities, teenagers, and those with multiple sexual partnerships. Viral STIs were less clearly associated with population subgroups and a broader population based approach to sexual health promotion may be more effective in controlling these infections.

Behavioural and demographic characteristics of attenders at two genitourinary medicine clinics in England.

OBJECTIVES: To investigate how attenders with sexually transmitted disease (STD) differ from the general population with respect to sexual behaviour, and to identify which attenders at genitourinary medicine (GUM) clinics are at particular behavioural risk for acquiring STD. DESIGN: Multicentre cross sectional survey. SETTING: Two genitourinary medicine clinics, one in London and one in Sheffield SUBJECTS: 20,516 patients attending the two clinics over an 18 month period. MAIN OUTCOME MEASURES: Behavioural and demographic characteristics and clinical diagnoses were recorded for each patient. RESULTS: 8862 patients, in whom 12,506 diagnoses were made, were seen in the Sheffield clinic, and 11,654 patients, in whom 20,243 diagnoses were made, were seen in the London clinic. When compared with the reported results from a general population survey, there were higher proportions of clinic attenders reporting two or more sexual partners in the preceding 12 months (p < 0.001), and a higher proportion of males reporting homosexual contact (13% compared with 1%, p < 0.001). Only age and number of sexual partners in the past 12 months were significantly associated with acute STDs for each sex in each clinic. Acute STDs tended to occur with greater frequency in the younger age groups, peaking among 16-19 year olds, particularly among females. CONCLUSIONS: The results have confirmed that patients with STDs exhibit higher risk sexual behaviour than the general population, and have highlighted the problem of continuing high risk behaviour among younger attenders, particularly younger homosexual men. This study has demonstrated that among GUM clinic attenders age and number of sexual partners are key risk factors for the acquisition of an acute STD. The results of this survey also indicate, however, that half of the females and more than one quarter of males with acute STDs reported only one sexual partner in the past 12 months, suggesting that health education messages should point out that it is not only those who have multiple recent sexual partners, or who have recently changed sexual partner, that are at risk of STD, including HIV.

Golgi study on neurons and fibers in Nucl. rotundus of the thalamus in chicks.

The structural arrangement of nucleus rotundus was studied by Golgi method. Large, multiangular principal neurons, their dendrites and dendritic terminals were observed. The long dendrites and their side-branches course parallel and/or perpendicular to each-other and they are arranged about in dorso-ventral latero-medial and rostro-caudal directions. The dendrites and their side-branches develop characteristic terminal branchings. These dendritic terminals overlap each-other and the area is called dendritic terminal field. The tecto-rotundal fibers traverse the nucleus in large bundles and the final sections of fibers join to the dendrites of principal neuron and terminate in dendritic terminal fields.

Problems of adolescents sexuality.

Recent discussions highlighted adolescents' sexual behaviour, but published studies concentrate on specific problems or subgroups of patients without addressing factors related to sexuality. To obtain a broad picture we studied two groups of adolescents attending genito-urinary medicine/sexually transmitted disease (STD) clinics in contrasting areas of Britain, inner London and Swansea. These were evaluated for referral pattern, sexual partner, contraception, obstetric history, sexually transmitted disease, and cervical cytology findings. Over half the adolescents referred themselves but few doctors other than general practitioners referred patients. Sexual partners were regarded by males as casual but by females as regular. Only 66% (81) of females practised contraception. Adolescents had more STD's than the total clinic population except for genital herpes simplex infection, and a high prevalence of genital warts in females has important future implications. The main conclusions were that there is a need for sexually related education targetted at adolescents and their health care providers, especially doctors.