Sex differences in pudendal somatosensory evoked potentials.

BACKGROUND: Somatosensory evoked potentials (SEPs) of the pudendal nerve are a well-established diagnostic tool for the evaluation of pelvic floor disorders. However, the possible influence of sex differences on response latencies has not been established yet. The aim of this study was to standardize the procedures and to evaluate possible effects of gender differences on anal and penile/clitoral SEPs. METHODS: The anal and dorsal penile/clitoral SEPs were recorded in 84 healthy subjects (40 males and 44 females; mean age 47.9 ± 16.6 years, range 16-81 years; mean height 168.3 ± 20.3 cm, range 155-187 cm). Pudendal SEPs were evoked with a bipolar surface electrode stimulating the clitoris or the base of the penis and the anal orifice and recorded using scalp electrodes. The latency of the first positive component (P1) was measured. The effect and possible interaction of (a) stimulation site and (b) gender on the two variables was explored by multivariate analysis of variance (MANOVA). RESULTS: The examination was well tolerated and a reproducible waveform of sufficient quality was obtained in all the subjects examined. In the female subjects, a mean cortical P1 latency of 37.0 ± 2.6 and 36.4 ± 3.2 ms for anal and clitoral stimulation, respectively, was found. In the male subjects, the cortical latencies were 38.0 ± 3.5 ms for the anal stimulation and 40.2 ± 3.7 ms for the penile stimulation. At MANOVA, a statistically significant main effect of stimulation site and gender as well as a significant interaction between the two variables was found. CONCLUSIONS: Anal and dorsal penile/clitoral SEPs represent a well-tolerated and reproducible method to assess the functional integrity of the sensory pathways in male and female subjects. Obtaining sex-specific reference data, by individual electrophysiological testing, is highly recommended because of significant latency differences between males and females, at least as far as penile/clitoral responses are concerned.

Bioavailability of l-thyroxine and its metabolites after topical treatment with an emulsion containing 0.1% micronised l-thyroxine.

AIM: Aim of the study was to assess systemic effects of a cycle of treatment with a topical formulation of l-T4 and escin (Somatoline®) in healthy women based on changes in bioavailability of FT4, FT3, rT3, and TSH. METHODS: This study enrolled 20 healthy adult women with body mass index <30, not exposed to iodine-containing products. The study called for 28 consecutive days of treatment with Somatoline® followed by a 14-day follow-up period. Blood samples for FT4, FT3 and TSH levels were drawn at baseline, 5 and 24 hours after the first application and thereafter on days 14, 28 and 42. Levels of rT3 were measured during the first 24 hours postapplication. RESULTS: Subject mean age was 40.1±8.0 years and BMI from 19.1 to 29.8. Levels of FT4 always remained within normal range and did not change in a clinically relevant way from baseline (11±1.2 pg/dL), with maximum mean change from pretreatment values of 0.4 pg/mL (P=0.87). Likewise, FT3 and TSH levels did not change significantly from baseline (3±0.4 pg/dL and 1.8 ±0.9 µU/mL, respectively). Levels of rT3 behaved in a similar way, with modest changes from baseline (P=0.29). Local tolerability was defined "excellent" for 19 out of 20 women (95%) and "moderate" in one subject who experienced the onset of folliculitis, for which causal correlation with the treatment was considered "possible". CONCLUSION: Used at the posology foreseen for the marketed formulation, Somatoline® does not affect plasma levels of FT4, FT3, rT3 and TSH, either in the short term or after 28 days.

Measurement of the anorectal angle by defecography for the diagnosis of fecal incontinence.

We assessed the reliability of anorectal angle (ARA) measurement as an index of fecal incontinence. The "posterior" ARA was measured at rest, squeezing, and straining in 69 continent and 82 incontinent subjects all complaining of various evacuation dysfunctions. The two groups were homogeneous with regard to sex distribution (48.6% vs. 51.4% men and 44.7% vs. 55.3% women, n.s.) and age (56.5 +/- 10.2 vs. 59.3 +/- 9.7 years, n.s.). The incidence of rectal prolapse was the same in the two groups (40 each). The intraobserver agreement index from two independent measurements (Pearson's correlation coefficient), age, and gender interaction [T2 Hotelling test in multivariate analysis of variance (ANOVA)] and the most discriminating category of ARA measurement (Fisher's F test in ANOVA) were calculated. In addition, the relationship between ARA and severity of incontinence was assessed by the eta coefficient. Pearson's correlation coefficient was between 0.78 and 0.98 (P < 0.01). The mean ARA differed significantly between the continent and incontinent subjects (104.5 +/- 10.3 degrees vs. 116.2 +/- 23.6 degrees at rest, 84.5 +/- 14.2 degrees vs. 95.1 +/- 20.1 degrees on squeezing, and 133.7 +/- 21.7 degrees vs. 141.7 +/- 25.9 degrees on straining; T2 0.066, P < 0.05 in multivariate ANOVA). No interaction was noted between groups and gender (T2 = 0.023; F = 1.11, n.s.). Resting ARA was shown by ANOVA to be the most discriminating index (F = 9.4 P < 0.01) between the two groups. Overall, ARA measurement was correlated with the severity of fecal incontinence (eta coefficient: 0.894 at rest; 0.811 on squeezing; 0.695 on straining); its accuracy was 79%, the false-positive rate was 15.3% and the false-negative rate 26.5%. Irrespective of the underlying abnormality, namely rectal prolapse, ARA measurement by defecography can: (a) be reinterpreted reliably by the same observer and (b) differentiate continent from incontinent subjects.

[Etiologic, prognostic and social health aspects of urinary infections in hospitalized elderly with an indwelling urinary catheter]. / Aspetti etiologici, prognostici e riflessi socio-sanitari delle infezioni delle vie urinarie in soggetti anziani ospedalizzati portatori di catetere vescicale a permanenza.

The aim of the study is to evaluate, in a short case-report, the concomitant urinary tract infections in a group of institutionalized elderly people with urinary indwelling catheter. Mental, functional and sanitary status was determined. 61 subjects over 65 years old (23 male and 38 female) were recruited and subdivided into three groups. Streptococcus faecalis was the main cause of urinary tract infections, Gram negative infections were overall predominant. High levels of dysautonomia with strong, global cognitive ability compromise were present in 75% of pattern. DMI and RSS test showed a marked not self-contained in 77% of recruited people and a high stress in the relatives. A significant statistical correlation among functional, sanitary, status and outcome institutionalization was present.

Predictive factors of callosotomy in drug-resistant epileptic patients with a long follow-up.

Some possible factors to predict outcome after callosotomy were investigated in a personal series composed of 36 patients. Twenty-seven of them were submitted to anterior callosotomy, 1 to posterior callosotomy and the remaining 8 patients to two stage complete division of corpus callosum. All factors, either positive or negative, do not appear completely reliable; they can be envisaged only in relative terms and do not seem to be relevant to make surgical decision or to discard surgery. In author's series, dealing specifically with drop-attacks, it clearly appeared that abrupt falls to the ground unpreceded by other epileptic features did definitely better. This was the only statistically significant datum.

EEG Patterns after callosotomy.

In 36 patients with drug-resistant epilepsy submitted to anterior callosotomy (27 cases), to two-stage total callosotomy (8 cases) and to posterior callosotomy (1 case) the EEG variations concerning background activity, focal activity and sharp-waves (SW) bisynchronous activity were evaluated. EEG modifications observed after callosotomy are the following: background rhythm tends to be better organised as spectral analysis demonstrated, this finding usually coincide with reduction of bisynchronous discharges. It appears that improvement in background activity cannot be correlated with outcome, but it seems to be to some extent since at the same time cognitive functions also seem to improve; however, this last aspect need to be checked in much larger series. The number and location of EEG foci do not change, but they appear to be more active; this is likely to depend only on the concomitant reduction of bisynchronous activity. No correlation seems to exist between the number and the location of foci, which are generally multiple. Lateralization of bisynchronous discharges as well as the reduction of their frequency and duration were observed. However, the clinical course is quite different: in some patients we have achieved good clinical responses in others postoperative results were poor. Lateralization of bisynchronous discharges is never absolute, on the grounds that in prolonged recordings bisynchronous discharges are nearly always present. Bisynchronous discharges in some cases are alternatively predominant in both hemispheres even within minutes or seconds. It was observed that after certain time, generally some months, lateralized discharges tend to generalize again, confirming that corpus callosum is replaced in discharge diffusion by other structures (brain-stem, diencephalon).

Mutism in 36 patients who underwent callosotomy for drug-resistant epilepsy.

Thirty-six drug-resistant epileptic patients submitted to callosotomy were studied. Anterior callosotomy was performed in 27 patients, total two-stage callosotomy was performed in 8 patients and 1 patient had only posterior callosotomy. We found mutism in 10 patients (2 after complete callosotomy and 8 after anterior section). The patients did not speak, but the comprehension was present: they were able to carry out orders and to write. Their attitude to the environment was characterized by complete indifference. The mutism was always transient, lasting from 4 to 25 days (mean 7 days). Regression of mutism was always complete. We think that this complication should be chiefly attributed mainly to surgical manipulation, even if it is impossible to completely exclude a multi-factorial etiology.

Dynamic imaging of the normal pelvic floor.

PURPOSE: To provide quantitative data by a modern cross-sectional imaging technique (CT) for defining normal physiological values of pelvic floor structures. PATIENTS AND METHODS: Twenty seven subjects, 7 males, 20 females, aged 20-75 yrs (mean 46.3 +/- 5 yrs) without pelvic floor or defection dysfunction underwent Direct Coronal (DC) CT scanning of the pelvis with the patient seated instead of lying. Scans obtained at rest and on straining were compared by bony landmarks. Three anatomical compartments, i.e. anterior, middle and posterior, were identified by two planes drawn tangential to the ischial foramina and the ischial tuberosities, respectively. Measurements of (1) Levator ani muscle length (mm); (2) Levator-anal angle (degrees); (3) Rectal floor-to-ischial line distance (mm) and (4) Supra/Infralevator spaces (square cm) were independently performed twice by two radiologists. The statistical analysis included calculation of intra and interobserver agreement (correlation coefficient). The differences between the means of the resting and straining values from each compartment (Student's t test) and the correlation between parameters (Pearson's coefficient) to evaluate whether resting values allowed a prediction of those on straining were determined. RESULTS: DC scans of diagnostic quality were obtained in all but two patients (92.5%). Both intra- and interobserver agreement indices were always greater than 80% (except for a 0.63 value by one observer obtained in the infralevator space from the anterior compartment at rest). A significant difference between the resting and straining values of all parameters was noted in the three compartments. At rest the levator ani muscle length was significantly shorter and the supralevator space smaller in the posterior compartment (48.3 +/- 7.9 mm vs 48.8 +/- 7 mm vs 42.6 +/- 9.4 mm, P < 0.05 and 70.6 +/- cm2 vs 66.9 +/- 11.5 cm2 vs 27.2 +/- 4.8 cm2, P < 0.01 anterior, middle and posterior respectively). On straining, these two parameters increased by +42% and +17.8%, respectively, in the same compartment, while the most pronounced variation of the infralevator space occurred in the middle compartment (-51.1%). The increase in the supralevator space correlated with a decrease in the rectal floor-to-ischial line distance and widening of the levator-anal angle (r = -0.64, P < 0.01 and 0.48, P < 0.05, respectively). A close correlation between resting and straining values was observed in all parameters, especially in the supralevator space in the three compartments (r = 0.82, 0.93 and 0.88, P < 0.01). CONCLUSIONS: Direct Coronal CT scanning showed that on straining the posterior component of the levator ani muscle, i.e. the coccygeus muscle, undergoes "physiological overstretching" and the supralevator space acts as a "compliant cavity", whose behaviour can be predicted at rest.

[Defecography in the diagnosis of fecal incontinence: an analysis of the receiver operating characteristic (ROC)]. / La defecografia nella diagnosi di incontinenza fecale: analisi delle receiver operating characteristic (ROC).

Two groups of patients with altered bowel habit and pelvic floor dysfunction, but comparable epidemiologic characteristics (i.e. n = 105 each; mean age and SD 47.3 +/- 15.8 yrs vs. 54.9 +/- 16.7 yrs; range 15-80 yrs vs. 9-88 yrs; F/M ratio 28:1 vs. 2.6:1) with the exception of the absence (or presence) of fecal incontinence, were examined with defecography, taking into account criteria other than anorectal angle values and anorectal junction mobility. At the Receiver Operating Characteristic (ROC) analysis a "barium leak sign", occurring either at rest or on straining was found to be a highly reliable index of fecal incontinence (specificity: 100% and 92-93%, respectively, intraobserver agreement K value = 0.82, Z = 21.58, p < 0.001). A false negative rate of 14.2% was limited to "minor" incontinence only, i.e., incontinence to gas and/or occasional staining episodes. In the search for an etiologic diagnosis, useful adjunctive criteria included (a) anal diameter > 10 mm at rest; (b) poor stop test (inability to interrupt the barium stream); (c) rectal diameter > 6.5 cm and < 4 cm (abnormally increased and reduced compliance, respectively). Defecography is a useful diagnostic tool in fecal incontinence and should precede anal endosonography, manometry and electromyography for proper therapeutic decision-making and in risk conditions, e.g., in the patients about to undergo elective pelvic surgery.

[Relationship between cholesterol levels and depression in the elderly]. / Associazione tra livelli di colesterolo e depressione nell'anziano.

The aim of our study is to evaluate the possible association between lower plasma cholesterol and depression in the elderly. 140 subjects over 65 years old of both sexes were enrolled, of which 60 were affected by depression (DSM-III-R and Hamilton test) and 80 composed a control group homogeneous for sex and age with the previous one. Plasma cholesterol, HLD-cholesterol (HDL-C), LDL-cholesterol (LDL-C) and triglycerides were measured. A statistically significant difference between cholesterol and LDL-C (p < 0.001) was noted in the total group, in both males and females. Such modifications were independent of sex. In the group with lower cholesterol (cut-off < = 160 mg/dl) a prevalence of depression three times greater than subjects with higher cholesterol was found. In conclusion, the authors recommended a prudent use of lipid-lowering medications in the elderly because of its uncertain benefits.

[Hyperuricemia and cardiac risK factors: epidemiologic study in the aged]. / Iperuricemia e rischio cardiovascolare: studio epidemiologico nell'anziano.

The aim of our study is to evaluate whether hyperuricemia may be considered a cardiovascular risk factor also in the elderly. 370 subjects over 60-years-old of both sexes were examined of which 148 presented an ischemic heart disease and 222, age and sex homogeneous, were considered as control group. Serum uric acid was determined. A strong difference among the two groups (p < 0.001) was statistically demonstrated. Such modifications were sex independent. A strict correlation of hyperuricemia and hyper trygliceridemia was present; in fact high uric acid levels were mostly found in the group with triglycerides > 200 mg/dl (p < 0.02). In the whole group and in males a stability of uric acid was noted. In females a significant increase among the first (60-69 years) and the second (70-79 years) age class was present. In conclusion, a positive role of hyperuricemia in the ischemic heart disease pathogenesis is possible.

Long-term metabolic control and retinopathy in type I diabetes: ten-year follow-up.

The causative relationship between metabolic control and long-term complications of diabetes is still under debate. Recent studies suggest that a strict glycemic control can often prevent the development of microcirculatory impairment but the role played by chronic hyperglycemia in the pathogenesis of retinopathy remains controversial. We report the results of a retrospective study of data collected on a ten-year period and concerning the relationship between glycemic control and retinopathy. A group of 46 Type I diabetic people was studied. Results indicate that the probability of developing retinopathy or of worsening the degree of a pre-existing retinopathy is higher in patients with poor metabolic control. Deterioration of metabolic control (increase of HbAlc% levels) appears to be related to a progression of retinal lesions. On the contrary, retinopathy is not influenced by aging and duration of diabetes mellitus.

Reconstruction of the anterior cruciate ligament with free grafting of the patellar tendon: surgical technique.

A free graft taken from the patellar tendon with a proximal and distal bone plug is used for the treatment of lesions of the anterior cruciate ligament; the authors emphasize the graft harvest procedure, the preparation of the graft, and its fixation, and specify that for the latter they prefer to anchor the traction wires of the neoligament to a proximal and a distal cortical screw.