Higher Neural Correlates in Patients with Multiple Sclerosis and Neurogenic Overactive Bladder Following Treatment with Intradetrusor Injection of OnabotulinumtoxinA.

PURPOSE: OnabotulinumtoxinA is a well described treatment of neurogenic overactive bladder. While motor effects on the detrusor muscle have been extensively studied, the sensory effects have not. The aim of this study was to evaluate the impact of intradetrusor onabotulinumtoxinA injection on brain activity in female patients with multiple sclerosis and neurogenic overactive bladder. MATERIALS AND METHODS: We prospectively studied 12 women with stable multiple sclerosis and neurogenic overactive bladder using concurrent functional magnetic resonance imaging and urodynamic studies prior to and 6 to 10 weeks following onabotulinumtoxinA injection. Individual functional magnetic resonance imaging activation maps at the time of strong urgency were averaged before and after onabotulinumtoxinA injection where areas of significant activation were identified. RESULTS: After onabotulinumtoxinA injection functional magnetic resonance imaging activation increased in the right cingulate body (p = 0.0012), the left posterior cingulate (p = 0.02), the left anterior cingulate (p = 0.0015), the right prefrontal cortex (p = 0.0015), the insula (p = 0.0138) and the pons micturition center (p = 0.05). Sparse areas showed decreased activity, including the left cerebellum (p = 0.001), the left fusiform gyrus (p = 0.065) and the bilateral lentiform nucleus (p = 0.026). CONCLUSIONS: Intradetrusor injection of onabotulinumtoxinA appeared to increase the activity of most brain regions known to be involved in the sensation and process of urinary urgency in female patients with multiple sclerosis and neurogenic overactive bladder. To our knowledge this is the first study of its kind to evaluate the possible effects of onabotulinumtoxinA at the human brain level where sensory awareness is located. This activation pattern may be used to further phenotype patients to optimize therapy or determine the sensory effects of onabotulinumtoxinA beyond the bladder.

Early discharge after lung resection is safe: 10-year experience.

BACKGROUND: The average hospitalization after lung resection is 6 days, but some patients are discharged early in the post-operative period. The patient factors associated with early discharge (ED) and the safety of this approach are unknown. We hypothesized that specific patient populations are associated with ED, and that complications in this practice are low. METHODS: A prospective database of lung resections performed at an academic medical center between Jan 1, 2007 and Jan 1, 2017 was queried. Demographic and outcome variables were assessed using standard techniques. ED was defined as the length of stay (LOS) for the quintile with the lowest LOS for patients with anatomic resection (AR) or patients with wedge resection (WR). We then compared clinical factors between patients with ED to those patients discharged by day 7, to determine factors associated with ED (relative to "average" discharge). RESULTS: During the study period, there were 922 AR and 1,150 WR performed. A total of 448 (39.0%) patients had WRED and 211 patients (22.9%) had ARED. The rate of WRED varied by surgeon, but ARED did not. ARED and WRED patients was associated with several factors, including younger age, better lung function, and were less likely to have elevated American Society of Anesthesiologist (ASA) class. Multivariable analysis suggested that patient factors and primary surgeon influence ED. WRED was associated with 30-day mortality of 0.22% vs. 1.14% for longer LOS (P=0.08). After AR, there were no post-operative deaths within 30 days among 211 patients discharged on postoperative day 1 or 2 [(vs. 2/541, 0.4%, P=0.376) with longer LOS, P=0.048]. CONCLUSIONS: ED after lung resection is multifactorial but is safe among selected patients. Age, lung function, procedure duration, and surgeon all influence ED. Complications after ED were rare. Individual surgeon comfort with ED likely impacts LOS, and education or enhanced recovery protocols may help overcome this barrier. Standardized pathways would likely help identify low-risk patients for expeditious discharge.

Predicting Gains With Visuospatial Training After Stroke Using an EEG Measure of Frontoparietal Circuit Function.

The heterogeneity of stroke prompts the need for predictors of individual treatment response to rehabilitation therapies. We previously studied healthy subjects with EEG and identified a frontoparietal circuit in which activity predicted training-related gains in visuomotor tracking. Here we asked whether activity in this same frontoparietal circuit also predicts training-related gains in visuomotor tracking in patients with chronic hemiparetic stroke. Subjects (n = 12) underwent dense-array EEG recording at rest, then received 8 sessions of visuomotor tracking training delivered via home-based telehealth methods. Subjects showed significant training-related gains in the primary behavioral endpoint, Success Rate score on a standardized test of visuomotor tracking, increasing an average of 24.2 ± 21.9% (p = 0.003). Activity in the circuit of interest, measured as coherence (20-30 Hz) between leads overlying ipsilesional frontal (motor cortex) and parietal lobe, significantly predicted training-related gains in visuomotor tracking change, measured as change in Success Rate score (r = 0.61, p = 0.037), supporting the main study hypothesis. Results were specific to the hypothesized ipsilesional motor-parietal circuit, as coherence within other circuits did not predict training-related gains. Analyses were repeated after removing the four subjects with injury to motor or parietal areas; this increased the strength of the association between activity in the circuit of interest and training-related gains. The current study found that (1) Eight sessions of training can significantly improve performance on a visuomotor task in patients with chronic stroke, (2) this improvement can be realized using home-based telehealth methods, (3) an EEG-based measure of frontoparietal circuit function predicts training-related behavioral gains arising from that circuit, as hypothesized and with specificity, and (4) incorporating measures of both neural function and neural injury improves prediction of stroke rehabilitation therapy effects.