Sensitivity and specificity of multichannel surface electromyography in diagnosing fecal incontinence.

BACKGROUND: Assessment of the neurocontrol of the external anal sphincter has long been restricted to investigating patients by invasive tools. Less invasive techniques have been regarded less suitable for diagnosis. OBJECTIVE: The aim was to develop a surface electromyography-based algorithm to facilitate fecal incontinence diagnosis, and to assess its sensitivity and specificity. DESIGN: Data analysis from a single center prospective study. PATIENTS: All patients from colorectal surgery office were considered. They underwent a structured interview, a general physical and proctologic examination. Patients with diagnosed fecal incontinence (Fecal Incontinence Severity Index >10) were included into the study group. The control group consisted of healthy volunteers that scored 5 or less and had negative history and physical exam. Both groups underwent the same tests (rectoscopy, anorectal manometry, transanal ultrasonography, multichannel surface electromyography and assessment of anal reflexes). METHODS: EMG results were analyzed to find parameters that would facilitate fecal incontinence diagnosis. OUTCOME MEASURES: Sensitivity and specificity of surface electromyography, to diagnose fecal incontinence, were assessed. RESULTS: A total of 49 patients were included in the study group (mean age ± SD 58.9 ± 13.8). The control group (n = 49) gender matched the study group (mean age ± SD 45.4 ± 15.1). The constructed classification tree, based on surface electromyography results, correctly classified 97% of cases. Thee sensitivity and specificity of this classification tree, to diagnose FI, was 96% and 98% respectively. LIMITATIONS: The age of women in the control group differs significantly from mean age of other groups. CONCLUSIONS: Surface electromyography is an good tool to facilitate diagnosing of fecal incontinence.

Sunitinib-induced hypothyroidism predicts progression-free survival in metastatic renal cell carcinoma patients.

Sunitinib is a tyrosine kinase inhibitor (TKI) used in treatment of metastatic renal cell carcinoma (mRCC), gastrointestinal stromal tumors and pancreatic neuroendocrine tumors. One of the most common side effects related to sunitinib is hypothyroidism. Recent trials suggest correlation between the incidence of hypothyroidism and treatment outcome in patients treated with TKI. This study evaluates whether development of hypothyroidism is a predictive marker of progression-free survival (PFS) in patients with mRCC treated with sunitinib. Twenty-seven patients diagnosed with clear cell mRCC, after nephrectomy and in 'good' or 'intermediate' MSKCC risk prognostic group, were included in the study. All patients received sunitinib as a first-line treatment on a standard schedule (initial dose 50 mg/day, 4 weeks on, 2 weeks off). The thyroid-stimulating hormone serum levels were obtained at the baseline and every 12 weeks of treatment. In statistic analyses, we used Kaplan-Meier method for assessment of progression-free survival; for comparison of survival, we used log-rank test. In our study, the incidence of hypothyroidism was 44%. The patients who had developed hypothyroidism had better median PFS to patients with normal thyroid function 28,3 months [95% (CI) 20.4-36.2 months] versus 9.8 months (6.4-13.1 months). In survival analysis, we perceive that thyroid dysfunction is a predictive factor of a progression-free survival (PFS). In the unified group of patients, the development of hypothyroidism during treatment with sunitinib is a positive marker for PFS. During that treatment, thyroid function should be evaluated regularly.

Bradycardia as a rare symptom of cisplatin cardiotoxicity: A case report.

Cisplatin (DDP) is one of the most frequently used chemotherapeutic agents, and has a characteristic toxicity profile. For DDP, complications affecting the cardiovascular system, which are typical for certain other agents, are rare; however, their occurrence may lead to life-threatening conditions. To the best of our knowledge, there are few reported cases of DDP-induced bradycardia in the relevant medical literature. The current report presents the case of a 58-year-old patient diagnosed with metastatic neuroendocrine carcinoma with a primary lesion in the posterior mediastinum, who was treated with DDP and etoposide chemotherapy. Following the initial chemotherapy cycle, the patient experienced severe symptomatic bradycardia (a drop in heart rate to 40 bpm), with the corrected QT interval prolonged to 424 msec. The patient's condition required close monitoring and treatment. Similar symptoms occurred following each of the three cycles of chemotherapy. Imaging studies performed following the third treatment cycle revealed disease progression, and the patient was referred for palliative care. Reports have indicated that damage to the cardiovascular system, including cardiac ischemia, diastolic disturbances, hypertension and microalbuminuria, may be associated with DDP-based therapy. However, the mechanism of DDP-associated cardiac toxicity remains to be elucidated. It may be induced by factors including direct toxicity, ion imbalance, heart infiltration and, in the case of neuroendocrine tumors, the influence of tumor excretions.

Co-occurring adverse events enable early prediction of progression-free survival in metastatic renal cell carcinoma patients treated with sunitinib: a hypothesis-generating study.

AIMS AND BACKGROUND: Clinical practice shows significant differences in treatment outcomes and toxicity of sunitinib across patients. This retrospective study assessed early predictive markers for progression-free survival (PFS) in patients with metastatic clear cell renal cell carcinoma (RCC) treated with sunitinib in the first-line setting. METHODS: We evaluated 28 patients with stage IV clear cell RCC (with good or intermediate MSKCC risk prognosis) treated at the Department of Oncology, University Hospital, Cracow between 2008 and 2013. Data included demographic profiles, adverse events during first cycle of therapy, treatment delays, and treatment outcomes. Sunitinib was administered on a standard schedule (50 mg/day, 4 weeks on, 2 weeks off). PFS values were estimated with the Kaplan-Meier method and compared using the log-rank test; we identified independent PFS predictors using multiple Cox regression models. RESULTS: PFS was significantly longer in patients who experienced at least 1 adverse event after the first cycle of sunitinib (median 17.6 months vs. 5.6; p = 0.006). Hypertension and hand-foot syndrome were significantly correlated with longer PFS (29.3 vs. 6.0 months; p = 0.002, and not reached vs. 9.8 months; p = 0.002, respectively). We observed a similar (though not significant) tendency for neutropenia (17.5 vs. 8.4 months; p = 0.055). In multiple Cox regression, hypertension was the only individual independent predictor of PFS, but the co-occurrence of any 2 or 3 sunitinib-induced adverse events also predicted longer survival. CONCLUSIONS: Although small, our study suggests that hypertension and hand-foot syndrome predict longer PFS in patients with clear cell RCC treated with sunitinib. The co-occurrence of 2 or more side effects seems also a significant predictor of longer survival. Larger studies are warranted to confirm the correlation between co-occurring side effects and PFS.

Variation in treatment modalities, costs and outcomes of rectal cancer patients in Poland.

AIM OF THE STUDY: To evaluate outcome, costs and treatment differences in rectal cancer patients between various regions in Poland. MATERIAL AND METHODS: Data from the Polish National Health Fund of all patients with rectal cancer diagnosed and treated between 2005 and 2007 were analyzed. Overall, relative 5-year survival and the percentage of patients receiving chemotherapy, radiotherapy and surgery were analyzed. The possible influence of cost of treatment per patient and mean number of rectal cancer patients per surgical oncologist were analyzed as well. RESULTS: In total 15,281 patients with rectal cancer were diagnosed and treated in Poland in 2005-2007 within the services of the National Health Fund. The overall, relative 5-year survival rate was 51.6%. Curative surgery was performed in 64.1% of patients. Radiotherapy and chemotherapy were used in 47.5% and 60.7% of patients, respectively. The mean cost of treatment of one rectal cancer patient was 32,800 PLN and there were 49.8 rectal cancer patients per specialist in surgical oncology. Important differences between regions were found in all these factors, but without a significant influence on survival. A correlation between numbers of patients per specialist in different voivodeships and survival rates was observed, as well as a correlation between percentage of surgical resection in voivodeships and survival rates (p = 0.07). CONCLUSIONS: Results of treatment of colorectal cancer in Poland improved significantly during the last decade. There exist however, important disparities between regions in terms of method of treatment, costs and outcomes.

Laparoscopically implanted system for stimulation of the hypogastric plexus induces colonic motility, defecation, and micturition: experimental study.

BACKGROUND: Modulation of the enteric nervous system seems to be promising in several functional colorectal disorders for which targeted, causal treatment methods do not exist. However, sacral nerve stimulation can induce undesirable muscle contraction or paresthesia. Therefore, we have developed a laparoscopic technique for implanting a neural electrode, placed directly over the pelvic autonomic nerve plexus. The aim of this experimental study was to evaluate the effect of stimulating the hypogastric plexus and pelvic nerves on inducing distal colon contraction, defecation, and micturition. METHOD: A total of 10 white, male healthy pigs (25-30 kg) were subjected to the laparoscopic implantation of the electrode and the stimulator. In the third and fourth weeks postimplantation, the efficacy of the acute and chronic stimulation to induce defecation was evaluated. RESULTS: The average operative time was 105 minutes (85-150 minutes). In all pigs, acute stimulation activated induced defecation, every second day, every time on demand, with an average delay of 139.7 s. Micturition was induced incidentally. Acute or chronic stimulation did not cause any harm, pain, or suffering to the animals. No adverse effects of the stimulation were observed, and no septic complications or macroscopic fibrosis around the electrodes were found on autopsy. CONCLUSION: Hypogastric plexus stimulation can be a useful and safe option of distal colon contraction, defecation, and micturition. However, the efficacy of the stimulation was observed for a relatively short period of time, and it is not known if it will be sustained for a longer duration.

Developing a new electromyography-based algorithm to diagnose the etiology of fecal incontinence.

PURPOSE: For surface electromyography (sEMG) to become widely used in fecal incontinence (FI) etiology assessment, one would have to create a simple, step-by-step, computer-aided, electromyography-based algorithm that would become the basis for a computer-aided diagnosis (CAD) system. Thus, the aim of this work was to develop such an algorithm. METHODS: Each patient included in the study underwent a structured medical interview, a general physical examination, and a proctological examination. Patients that scored more than 10 points on the fecal incontinence severity index (FISI) underwent further tests that included rectoscopy, anorectal manometry, transanal ultrasonography, multichannel sEMG, and assessment of anal reflexes. Patients with fully diagnosed FI were included into the study group. The control group consisted of healthy volunteers that scored five or less points on the FISI and had no known anal sphincters dysfunction. RESULTS: Forty-nine patients were qualified to the study group (age ± SD 58.9 ± 13.8). The control group was number- and gender-matched (age ± SD 45.4 ± 15.1). The sensitivity and specificity of classification tree number I, to diagnose neurogenic FI, were 89.5 and 86 %, respectively. For patients with idiopathic FI, these values were 82 and 91 %, respectively. The sensitivity and specificity of classification tree number III, to diagnose neurogenic FI, were 84 and 78 %, respectively. For patients with idiopathic FI, these values were 78 and 87 %, respectively. CONCLUSIONS: The relative simplicity and low classification costs allow to assume that algorithms based on classification trees I and III will serve to be the basis for a FI etiology CAD system.

Occipital C1-C2 neuromodulation decreases body mass and fat stores and modifies activity of the autonomic nervous system in morbidly obese patients--a pilot study.

BACKGROUND: Autonomic and vagal neuromodulation has been suggested for the treatment of morbid obesity. Occipital nerves remain in close anatomical relation to vagal nerve roots at the entrance to medulla oblongata. The aim of the study was to evaluate the effect of C1-C2 occipital neuromodulation on autonomic activity, body mass, and composition. METHODS: Five obese patients were included in the study (three women and two men, BMI 43-49, average age 43.3, range 24-55). Two electrodes were placed bilaterally in the C1-C2 region subcutaneously under local anesthesia. Stimulation was started 24 h after implantation and continued for 8 weeks. Patients activated stimulators for 12 h every day and turned the stimulators off at night. No other treatment including diet or change in lifestyle was introduced during the study. The following parameters were evaluated: body mass (0, 4th, and 8th week), body composition (bioimpedance study), food intake, quality of life, and heart rate variability (HRV) (0 and 8th week). RESULTS: No adverse events were observed in this group. One patient reported amelioration of constipation and one reported two incidents of salivation. The average body mass decrease was 5.6 kg in 4 weeks and 8.7 kg in 8 weeks. Body composition study showed a 2-month decrease in body fat of 7.9 kg on average. HRV revealed increased parasympathetic tone (LF/HF 4.4 ± 4.3 SD vs. 1.6 ± 1.7 SD). CONCLUSIONS: C1-C2 occipital stimulation seems being capable of decreasing body mass and affecting a positive shift in body composition and significantly increases the activity of the autonomic nervous system.

[The changes in complete blood count in patients treated with sunitinib malate for metastatic clear cell renal cell carcinoma]. / Zmiennosc parametrów morfotycznych krwi u pacjentów leczonych sunitynibem z powodu raka jasnokomórkowego nerki w stadium uogólnienia.

Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies. For stage I - III RCC surgery is the primary treatment. Systemic therapy is used in the patients with disseminated disease (stage IV). Sunitinib malate is commonly used in the patients with clear cell renal cell carcinoma (ccRCC) rated as 'low' or 'intermediate' risk according to the Motzer scale. Treatment with sunitinib malate is associated with myelotoxicity. To assess its clinical significance we conducted a pilot study in a group of 10 patients. We noticed a gradual decrease in the mean haemoglobin level during subsequent treatment cycles. Alternations in the platelet count were of no clinical significance. Episodes of the neutropenia were noticed in the study group. In some patients neutrophil count decreased to the level that put them at risk of the infectious complications.

Doppler-guided hemorrhoid artery ligation with Recto-Anal-Repair modification: functional evaluation and safety assessment of a new minimally invasive method of treatment of advanced hemorrhoidal disease.

PURPOSE: We present 12-month followup results of functional evaluation and safety assessment of a modification of hemorrhoidal artery ligation (DGHAL) called Recto-Anal-Repair (RAR) in treatment of advanced hemorrhoidal disease (HD). METHODS: Patients with grade III and IV HD underwent the RAR procedure (DGHAL combined with restoration of prolapsed hemorrhoids to their anatomical position with longitudinal sutures). Each patient had rectal examination, anorectal manometry, and QoL questionnaire performed before 3 months, and 12 months after RAR procedure. RESULTS: 20 patients completed 12-month followup. There were no major complications. 3 months after RAR, 5 cases of residual mucosal prolapse were detected (25%), while only 3 patients (15%) reported persistence of symptoms. 12 months after RAR, another 3 HD recurrences were detected, to a total of 8 patients (40%) with HD recurrence. Anal pressures after RAR were significantly lower than before (P < 0.05), and the effect was persistent 12 months after RAR. One patient (5%) reported occasional soiling 3 months after RAR. CONCLUSIONS: RAR seems to be a safe method of treatment of advanced HD with no major complications. The procedure has a significant influence on anal pressures, with no evidence of risk of fecal incontinence after the operation.

[Selective Doppler-guided hemorrhoidal artery ligation as a minimaly invasive method of treatment of hemorrhoidal disease]. / Selektywne kontrolowane doplerem podwiazanie naczyn hemoroidalnych jako nieinwazyjna metoda leczenia choroby hemoroidalnej.

The aim of this study was to present the experience of two centres concerning minimal invasive technique for treating hemorrhoids--Doppler Guided Hemorrhoidal Artery Ligation (DGHAL). From our own experience and based on the literature--we can say that DGHAL is a minimally invasive, safe and effective method in grade II and III hemorrhoids. It can also be recommended in selected grade IV cases combined with anodermal folds resection. A properly carried out operation should involve no intra- and postoperative complications. However, this procedure requires more controlled trials on a larger group of patients and long term follow-up (longer than 3 years postoperatively).

Two-center experience in the treatment of hemorrhoidal disease using Doppler-guided hemorrhoidal artery ligation: functional results after 1-year follow-up.

INTRODUCTION: Doppler-guided hemorrhoidal artery ligation (DGHAL), as a method of treating hemorrhoidal disease, is currently used in many centers across Europe, Asia, and Australia. The aim of our study was to evaluate the clinical effectiveness and functional results of DGHAL as estimated by means of anorectal manometry. MATERIALS AND METHODS: Between 2000 and 2006 the DGHAL procedure was performed on 507 patients with II-IV degree hemorrhoids in two centers (Poland and Austria). Three hundred eight patients were included in the initial phase of the study, designed to estimate the method's effectiveness. During the second phase (199 patients) selected functional results were also assessed. Patients were classified as having grade II (144), III (319), and IV (44) hemorrhoids. RESULTS: There were no intra- and immediate postoperative complications. Good results were reported by 351 patients (69.2%), and were acceptable in a further 75 cases (4.8%). When the patients were grouped according to the stage of hemorrhoidal disease, 133 out of 144 patients (92.4%) with grade II and 272 out of 324 (84%) with grade III had very good or good results. Only 18 out of 44 patients (41%) with grade IV were satisfied with the operation. Fifty-nine patients after anorectal folds, fissure or anal canal polyp excision required analgesics for 1-2 days. Apart from lower contraction amplitude and contraction speed after 1 month there were no differences in anorectal functional tests. CONCLUSION: Based on our results we may conclude that DGHAL is a safe and effective method and may offer an important alternative to operative hemorrhoidectomy with no risk of postoperative stool incontinence, minimal postoperative pain, and early return of patients to their normal activities. Nevertheless, this is a fairly new procedure with a short-term follow-up. Until 5-year observations of large, multicenter, randomized trials are published we cannot recommend this method as a gold-standard procedure, although it still can offer significant benefits to patients.

Non-invasive assessment of the gracilis muscle by means of surface electromyography electrode arrays.

PURPOSE: The purpose of the study was the non-invasive investigation of the innervation zone (IZ) location of the gracilis muscle of both thighs by means of surface electromyography (EMG). MATERIALS AND METHODS: Multichannel EMG signals were detected by means of a flexible array of 16 equally spaced silver bar electrodes. Tests were performed on both gracilis muscles on 15 subjects. Motor unit (MU) action potentials were visually identified and extracted. The locations of the IZs of the recognized MUs were statistically analyzed to find significant differences between the subjects and between the right and left muscle of each subject. RESULTS AND CONCLUSIONS: A statistically significant difference was found between the gracilis IZ position in the two sides, with more proximal IZs on the left side. This difference suggests a possible role of surface EMG in preoperative evaluation of patients prepared for the dynamic graciloplasty procedure. This test would provide an objective criterion for the choice of the gracilis muscle to be transposed with the highest probability of success.

24-hour heart rate variability in patients with gastroesophageal reflux disease.

The GERD pathogenesis may be associated with disturbances of the autonomic nervous system (ANS), which can be revealed using heart rate variability studies (HRV). The aim of presented study was to estimate the circadian ANS activity in 24-hour HRV recordings in GERD patients, both in non-erosive form (NERD), and with erosive, inflammatory changes in the esophagus (ERD patients). Our results demonstrated disturbances in the parasympathetic ANS part, but they also delivered the proofs for possible sympathetic disorder. That is why the autonomic neuropathy in GERD patients may have mixed character.

[Current concepts of diverticular disease pathophysiology]. / Wspólczesne poglady na patofizjologifie uchylkowatosci jelita grubego.

The first description of diverticular disease (DD) is dated on XVIIIth century. During last decades the DD prevalence continuously increases, especially in western countries. Nowadays, in developed countries, DD of the left colon is one of the most common diseases of gastro-intestinal tract. Because of the prevalence and costs of treatment it is still in the limelight of scientists and medical professionals. This article summarizes basic epidemiological data and discusses actual concepts of DD pathophysiology. Despite fact DD becomes more and more important, its pathophysiology remains to be unrevealed yet. Further clinical, molecular and epidemiological studies are needed to show the process and particular stages of diverticula development and progression.

[Biofeedback as a conservative treatment of fecal incontinence]. / Biofeedback jako zachowawcza metoda leczenia nietrzymania stolca.

Faecal incontinence (SI) is defined as uncontrolled evacuation of stool in an inappropriate time or place, occurring at least two times a month. The other definition of SI is an inability to refrain from defecation till the moment thought to be appropriate from sociologic point of view. SI is an extremely stressful disease, which according to different sources, concerns about 2.5 to 7% of the adult population. The frequency of SI incidence raises with age, and it concerns about 60% of patients in geriatric health--care institutions. Nowadays there are many types of casual treatment of SI. One of the "first line" methods, if there is no extensive mechanical injury of sphincteric complex, is biofeedback (BF) training. In our study we presented principles of biofeedback treatment, a historical outline of the mentioned method and other conservative methods of SI treatment. We also presented, on the basis of literature, actual state of art concerning effectiveness and possibilities of therapeutic application of BF and results of clinical research, concerning application of BF training in faecal continence impairment in the adult population.

Anorectal and urinary dysfunction after surgery for rectal cancer.

AIM: Despite several studies conducted, the relationship between anorectal and urinary dysfunction has not been ultimately determined. METHODS: Forty four patients have been included into the study and divided into three groups according to the type of procedure: Group A - abdomino-perineal resection, group B - low anterior resection and group C - local excision. The urodynamic workup performed 5-9 months after surgical procedure consisted of uroflowmetry, residual urine volume measurement, and cystometry. The following urodynamic parameters were evaluated: sensory threshold, maximal urethral flow within first 30% of voiding time and during the first 5 seconds. Residual volume was controlled by abdominal ultrasound. Anal pressure profile was recorded for evaluation of resting and squeeze anal pressure, length of anal high-pressure zone, radial asymmetry and vector volume. Patients were asked to fulfil a standard questionnaire of voiding dysfunction and fecal continence. RESULTS: Mean values for groups A, B and C revealed for anorectal symptoms 4.7 (SD 3.4), unaffordable symptoms 3.0 (SD 3.3), and for urinary symptoms 2.5 (SD 2.0), 2.9 (SD 1.9), 0.2 (SD 0.6), respectively. Coexistence and aggravation of anorectal and/or urinary symptoms revealed high correspondence within group B (p = 0.055), while this kind of correlation was not observed in group C. Urinary disturbances suggested in uroflowmetric study were the most common in group B (90%). The percentage of patients with manometrically confirmed dysfunction after low anterior rectal resection was twice the value, as compared to the percentage of patients after local excision (p < 0.05). CONCLUSIONS: Our data revealed significant correlation between anorectal and urinary dysfunction after rectal surgery and suggests partially similar pathomechanism of these malfunctions, mediated by direct damage to pelvic autonomic plexus during extended rectal dissection for oncological reasons.

[Microchip neuromodulation of the autonomic system with magnetic field energy supply]. / Neuromodulacja czynnosci wegetatywnych z uzyciem neurowszczepów zasilanych polem magnetycznym.

We describe technical solution of the problem MC magnetic field energy supply showing that system is effective in the neuromodulation of the vagal activity associated with food intake. Effect of MC on decrease of food intake were related to strength of the magnetic field (19-350).