Continuous vs stepwise anal acoustic reflectometry: An improved technique for physiological measurement of anal sphincter function?

BACKGROUND: Anal acoustic reflectometry (AAR) is a technique for measuring the physiological profile of the anal canal, primarily the internal anal sphincter. Evaluation of a new continuous method, recently developed for the urethra, would enable its future application for investigation of rectal reflexes. METHODS: Patients aged 18 and over with fecal incontinence (FI) were included. Stepwise AAR parameters were compared with continuous opening pressure (Op, cmH2 O), opening elastance (Oe, cmH2 O/mm2 ), closing pressure (Cp, cmH2 O), closing elastance (Ce, cmH2 O/mm2 ), hysteresis (Hys, [%]), squeeze opening pressure (SqOp, cmH2 O), and squeeze opening elastance (SqOe, cmH2 O/mm2 ). Vaizey incontinence and Manchester Health Questionnaire scores were also collected. RESULTS: Thirty-two patients, 26 females were analyzed. Median age: 60 (range, 32-75). Median AAR parameters of Op (37.50 vs 35.15, P = .031), Oe (1.31 vs 0.84, P < .0001), Ce (1.11 vs 0.88, P < .0001), Hys (37.75 vs 19.04, P < .0001), and SqOe (1.27 vs 1.06, P = .005) were significantly higher with the continuous method. Cp (22.70 vs 27.22, P = .003) is lower and SqOp (96.87 vs 59.47, P = .71) not significantly different. The continuous technique had superior repeatability between cycles for all AAR parameters except Oe, which was equivalent and continuous SqOp had a stronger negative correlation with Vaizey score than stepwise (-0.46, P = .009 vs -0.37, P = .038). CONCLUSIONS: The differences seen between the two techniques are likely to be related to the rate of stretch. The continuous technique appears to represent a more physiological measurement of anal sphincter function than the stepwise technique particularly in the assessment of voluntary squeeze function.

Methodologic Validation of a Faster Pelvic Floor Test: Two Randomized Studies in Anal Acoustic Reflectometry.

BACKGROUND: Anal acoustic reflectometry investigates the opening and closing function of the anal canal using reflected sound waves to measure a cross-sectional area at different pressures. Anal acoustic reflectometry is reliable and repeatable, distinguishes between continence and incontinence and between subgroups of incontinence, correlates with symptom severity, and does not distort the anal canal during investigation. OBJECTIVE: The purpose of this study was to validate anal acoustic reflectometry methodology by asking 2 questions: can anal acoustic reflectometry be used alongside manometry (order study) and can anal acoustic reflectometry be performed faster (filling study). The secondary aim was to assess the response of the anal canal to stretch using anal acoustic reflectometry. DESIGN: This research included 2 prospective randomized studies. SETTINGS: The study was conducted at a tertiary referral center. PATIENTS: Patients undergoing investigation for fecal incontinence were included. INTERVENTION: For the order study, patients were prospectively randomized to anal acoustic reflectometry, manometry, 2-minute rest and then manometry, anal acoustic reflectometry, or vice versa. For the filling study, patients were prospectively randomized to fast rate anal acoustic reflectometry (5 cm H2O/1 s), manometry, 2-minute rest and then manometry, normal rate anal acoustic reflectometry (5 cm H2O/3 s), or vice versa. MAIN OUTCOME MEASURES: The primary outcome was no difference in anal acoustic reflectometry or manometry variables. Demographic and clinical data were recorded. RESULTS: The order study included 30 patients with a median age of 63 years (range, 30-84 y); 77% were women. No difference was found among all of the variables of anal acoustic reflectometry and manometry regardless of which test was performed first. The filling study included 50 patients with a median age of 62 years (range, 30-78 y); 80% were women. No difference was found between fast and normal rates of anal acoustic reflectometry and manometry in any order. LIMITATIONS: This study was limited by its comparison with water-perfused manometry. CONCLUSIONS: Anal acoustic reflectometry and manometry can be performed at the normal or fast rate of anal acoustic reflectometry in any order. A fast rate of anal acoustic reflectometry did not augment the response of the anal canal to stretch as measured by anal acoustic reflectometry and manometry. This study validates a faster anal acoustic reflectometry technique and vindicates previous data. See Video Abstract at http://links.lww.com/DCR/A821.

The short-term effects of posterior tibial nerve stimulation on anorectal physiology in patients with faecal incontinence: a single centre experience.

BACKGROUND: Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters. METHODS: Fifty patients with FI underwent 30 min of PTNS treatment, weekly for 12 weeks. High-resolution anorectal manometry, bowel diaries and Vaizey questionnaires were performed before and after treatment. Successful treatment was determined as a greater than 50% reduction in FI episodes. RESULTS: Fifty patients with FI were studied; 39 women, median age 62 years (range 30-82). Compared with pretreatment, there were reductions in episodes of urgency (16.0 versus 11.4, p = 0.006), overall FI (14.5 versus 9.1, p = 0.001), urge FI (5.4 versus 3.2, p = 0.016) and passive FI (9.1 versus 5.9, p = 0.008). Vaizey score was reduced (16.1 versus 14.5, p = 0.002). Rectal sensory volumes (ml) decreased (onset 40.3 versus 32.6, p = 0.014, call 75.7 versus 57.5, p < 0.001, urge 104.1 versus 87.4, p = 0.004). There was no significant change in anal canal pressures (mmHg) (maximum resting pressure 41.4 versus 44.2, p = 0.39, maximum squeeze pressure, 78.7 versus 88.2, p = 0.15, incremental squeeze pressure 37.2 versus 44.1, p = 0.22). Reduction in FI episodes did not correlate with changes in physiological parameters (p > 0.05). Treatment success of 44% was independent of changes in manometric parameters (p > 0.05). CONCLUSIONS: PTNS has a measureable physiological effect on rectal sensory volumes without an effect on anal canal pressures. It also reduces FI episodes; however, this effect is independent of changing physiology, suggesting that PTNS has a complex mechanism of action.

Improving accuracy of clinical coding in surgery: collaboration is key.

BACKGROUND: Clinical coding data provide the basis for Hospital Episode Statistics and Healthcare Resource Group codes. High accuracy of this information is required for payment by results, allocation of health and research resources, and public health data and planning. We sought to identify the level of accuracy of clinical coding in general surgical admissions across hospitals in the Northwest of England. METHOD: Clinical coding departments identified a total of 208 emergency general surgical patients discharged between 1st March and 15th August 2013 from seven hospital trusts (median = 20, range = 16-60). Blinded re-coding was performed by a senior clinical coder and clinician, with results compared with the original coding outcome. Recorded codes were generated from OPCS-4 & ICD-10. RESULTS: Of all cases, 194 of 208 (93.3%) had at least one coding error and 9 of 208 (4.3%) had errors in both primary diagnosis and primary procedure. Errors were found in 64 of 208 (30.8%) of primary diagnoses and 30 of 137 (21.9%) of primary procedure codes. Median tariff using original codes was £1411.50 (range, £409-9138). Re-calculation using updated clinical codes showed a median tariff of £1387.50, P = 0.997 (range, £406-10,102). The most frequent reasons for incorrect coding were "coder error" and a requirement for "clinical interpretation of notes". CONCLUSIONS: Errors in clinical coding are multifactorial and have significant impact on primary diagnosis, potentially affecting the accuracy of Hospital Episode Statistics data and in turn the allocation of health care resources and public health planning. As we move toward surgeon specific outcomes, surgeons should increase collaboration with coding departments to ensure the system is robust.

Beware the syndrome in neonatal hip instability: follow up assessment is required after apparent resolution.

Developmental dysplasia of the hip is one of the most common congenital musculoskeletal disorders of childhood, affecting 1-3% of newborns. An early diagnosis and prompt treatment is essential to avoid complex treatments and achieve improved results. Since 1992, we have undertaken a screening programme for clinical instability and at risk patients. During this time, there have been only two cases which have been normal on both clinical, and, static and dynamic ultrasound assessment, that have subsequently deteriorated. In these two cases there was an underlying syndrome associated with hyperlaxity, which behaves unpredictably compared to 'true' developmental dysplasia of the hip. In conclusion, if a hip has been referred as unstable but it is found to have a primary syndromal cause (especially if hyper lax) with sonographically normal hips at one to two weeks of age, it is best to review clinically and sonographically at 6 weeks and 3 months of age to confirm that the hip is maintaining stability.