Initial experience with home therapeutic electrical stimulation for continence in the myelomeningocele population.

PURPOSE: In an attempt to enhance bladder and bowel continence 29 patients underwent long duration, low intensity transcutaneous therapeutic electrical stimulation. This technology has previously been shown to be effective for inducing regenerative hypertrophy of disuse atrophied skeletal muscle, and it has been associated with improved continence in the myelomeningocele population. Our objectives were to enhance urinary and fecal continence, and evaluate the mechanisms by which therapeutic electrical stimulation influences continence. MATERIALS AND METHODS: A total of 29 children with lumbar or sacral myelomeningocele underwent therapeutic electrical stimulation at home during sleep using a commercially available stimulator with a safety sensing circuit and 2 sets of electrodes placed on the skin at bedtime. Left and right side electrode placement was alternated on 6 of 7 consecutive nights. In 9 boys and 2 girls with more than 9 months of followup initial and subsequent cystometrography, urethral pressure profile, electromyography, voiding cystourethrography and renal ultrasound studies were evaluated. RESULTS: In the 11 children there was no radiographic evidence of urinary tract or musculoskeletal deterioration during treatment. Mean actual bladder capacity increased from 133 to 196 ml. (p < 0.05). Mean bladder capacity, as a percent of maximum predicted bladder capacity for a normal age matched child without myelomeningocele, also significantly increased from 59 before to 76% after 9 months of therapeutic electrical stimulation (p < 0.05). No significant change was noted in urethral pressure profile. A subjective improvement in the sensation of pelvic fullness was also observed. CONCLUSIONS: When administered at home by parents while the child sleeps, therapeutic electrical stimulation is safe for bladder and bowel continence in the myelomeningocele population. It seems to increase significantly bladder capacity, does not appear to change urethral pressure profile and results in a subjectively improved sensation of pelvic fullness, enhancing urinary and fecal continence. The most beneficial effect of therapeutic electrical stimulation seems to be on the bladder wall and less so on the striated pelvic floor musculature with subjective enhancement of pelvic fullness also contributing positively.

Stryker frame gantry modification for extracorporeal shock wave lithotripsy to circumvent positioning problems.

From July 1986 through December 1989, 45 patients with renal or biliary calculi were treated on a Dornier HM3* lithotriptor using a Stryker frame gantry modification. The modification was necessary due to inability to position the patients in the standard gantry. The situations that required nonstandard positioning techniques included stones in the distal or mid ureter, renal transplant, gallbladder or common bile duct, and unusual body habitus, such as myelomenigocele, bilateral lower extremity amputations and children with stones. Positioning with adequate focus of the shock wave was achieved in 87% of the patients and fragmentation was achieved in 89%. The Stryker frame gantry modification is an excellent method to circumvent positioning problems with the Dornier HM3 lithotriptor, extending lithotripsy capability to patients who might otherwise not be candidates.

Effect of parenteral immunization on the local immunoglobulin A response of the intestine to Shigella flexneri antigens.

Most traditional methods of immunization involve parenteral vaccines. Using a chronically isolated ileal loop model as the probe, we examined the effect of a primary parenteral immunization on the local immune response of the intestine. Secretions from isolated ileal loops of rabbits given a primary parenteral immunization with Shigella flexneri without adjuvant showed a small, but definite, specific immunoglobulin A (IgA) response locally, whereas a vigorous serum antigen-specific IgG response was elicited. Also, stronger antigen-specific IgG activity was detected in secretions of parenterally immunized animals than from animals given shigella only by oral immunization. No local IgA or IgG memory response could be elicited by prior parenteral priming with S. flexneri antigens. Lastly, no increase in the primary local IgA response was found in secretions from animals given an oral dosage regimen previously shown to prime for mucosal memory and then challenged with a single parenteral dose of the same antigen. These studies demonstrate that without adjuvant, parenteral doses of S. flexneri antigens elicit both specific serum and local immune responses, but they are not able to prime for a mucosal memory response upon subsequent mucosal challenge. The implications of these findings for programs that use parenteral vaccination to protect against mucosal diseases are discussed.