Double-blind randomised controlled trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in the treatment of faecal incontinence: CONtrol of Faecal Incontinence using Distal NeuromodulaTion (the CONFIDeNT trial)

Background: Faecal incontinence (FI) is a common condition which is often under-reported. It is distressing for those suffering from it, impacting heavily on their quality of life. When conservative strategies fail, treatment options are limited. Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive outpatient treatment, shown in preliminary case series to have significant effectiveness; however, no randomised controlled trial has been conducted. Objectives: To assess the effectiveness of PTNS compared with sham electrical stimulation in the treatment of patients with FI in whom initial conservative strategies have failed. Design: Multicentre, parallel-arm, double-blind randomised (1 : 1) controlled trial. Setting: Eighteen UK centres providing specialist nurse-led (or equivalent) treatment for pelvic floor disorders. Participants: Participants aged > 18 years with FI who have failed conservative treatments and whose symptoms are sufficiently severe to merit further intervention. Interventions: PTNS was delivered via the Urgent® PC device (Uroplasty Limited, Manchester, UK), a hand-held pulse generator unit, with single-use leads and fine-needle electrodes. The needle was inserted near the tibial nerve on the right leg adhering to the manufacturer’s protocol (and specialist training). Treatment was for 30 minutes weekly for a duration of 12 treatments. Validated sham stimulation involved insertion of the Urgent PC needle subcutaneously at the same site with electrical stimulation delivered to the distal foot using transcutaneous electrical nerve stimulation. Main outcome measures: Outcome measures were assessed at baseline and 2 weeks following treatment. Clinical outcomes were derived from bowel diaries and validated, investigator-administered questionnaires. The primary outcome classified patients as responders or non-responders, with a responder defined as someone having achieved ≥ 50% reduction in weekly faecal incontinence episodes (FIEs). Results: In total, 227 patients were randomised from 373 screened: 115 received PTNS and 112 received sham stimulation. There were 12 trial withdrawals: seven from the PTNS arm and five from the sham arm. Missing data were multiply imputed. For the primary outcome, the proportion of patients achieving a ≥ 50% reduction in weekly FIEs was similar in both arms: 39 in the PTNS arm (38%) compared with 32 in the sham arm (31%) [odds ratio 1.28, 95% confidence interval (CI) 0.72 to 2.28; p = 0.396]. For the secondary outcomes, significantly greater decreases in weekly FIEs were observed in the PTNS arm than in the sham arm (beta –2.3, 95% CI –4.2 to –0.3; p = 0.02), comprising a reduction in urge FIEs (p = 0.02) rather than passive FIEs (p = 0.23). No significant differences were found in the St Mark’s Continence Score or any quality-of-life measures. No serious adverse events related to treatment were reported. Conclusions: PTNS did not show significant clinical benefit over sham electrical stimulation in the treatment of FI based on number of patients who received at least a 50% reduction in weekly FIE. It would be difficult to recommend this therapy for the patient population studied. Further research will concentrate on particular subgroups of patients, for example those with pure urge FI. Trial registration: Current Controlled Trials ISRCTN88559475. Funding: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 77. See the NIHR Journals Library website for further project information

A randomised controlled trial and economic evaluation of intraoperative cell salvage during caesarean section in women at risk of haemorrhage: the SALVO (cell SALVage in Obstetrics) trial

Background Caesarean section is associated with blood loss and maternal morbidity. Excessive blood loss requires transfusion of donor (allogeneic) blood, which is a finite resource. Cell salvage returns blood lost during surgery to the mother. It may avoid the need for donor blood transfusion, but reliable evidence of its effects is lacking. Objectives To determine if routine use of cell salvage during caesarean section in mothers at risk of haemorrhage reduces the rates of blood transfusion and postpartum maternal morbidity, and is cost-effective, in comparison with standard practice without routine salvage use. Design Individually randomised controlled, multicentre trial with cost-effectiveness analysis. Treatment was not blinded. Setting A total of 26 UK obstetric units. Participants Out of 3054 women recruited between June 2013 and April 2016, we randomly assigned 3028 women at risk of haemorrhage to cell salvage or routine care. Randomisation was stratified using random permuted blocks of variable sizes. Of these, 1672 had emergency and 1356 had elective caesareans. We excluded women for whom cell salvage or donor blood transfusion was contraindicated. Interventions Cell salvage (intervention) versus routine care without salvage (control). In the intervention group, salvage was set up in 95.6% of the women and, of these, 50.8% had salvaged blood returned. In the control group, 3.9% had salvage deployed. Main outcome measures Primary – donor blood transfusion. Secondary – units of donor blood transfused, time to mobilisation, length of hospitalisation, mean fall in haemoglobin, fetomaternal haemorrhage (FMH) measured by Kleihauer–Betke test, and maternal fatigue. Analyses were adjusted for stratification factors and other factors that were believed to be prognostic a priori. Cost-effectiveness outcomes – costs of resources and service provision taking the UK NHS perspective. Results We analysed 1498 and 1492 participants in the intervention and control groups, respectively. Overall, the transfusion rate was 2.5% in the intervention group and 3.5% in the control group [adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42 to 1.01; p = 0.056]. In a planned subgroup analysis, the transfusion rate was 3.0% in the intervention group and 4.6% in the control group among emergency caesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 1.8% in the intervention group and 2.2% in the control group among elective caesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46, suggesting that the difference in effect between subgroups was not statistically significant). Secondary outcomes did not differ between groups, except for FMH, which was higher under salvage in rhesus D (RhD)-negative women with RhD-positive babies (25.6% vs. 10.5%, adjusted OR 5.63, 95% CI 1.43 to 22.14; p = 0.013). No case of amniotic fluid embolism was observed. The additional cost of routine cell salvage during caesarean was estimated, on average, at £8110 per donor blood transfusion avoided. Conclusions The modest evidence for an effect of routine use of cell salvage during caesarean section on rates of donor blood transfusion was associated with increased FMH, which emphasises the need for adherence to guidance on anti-D prophylaxis. We are unable to comment on long-term antibody sensitisation effects. Based on the findings of this trial, cell salvage is unlikely to be considered cost-effective. Future work Research into risk of alloimmunisation among women exposed to cell salvage is needed. Trial registration Current Controlled Trials ISRCTN66118656. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 2. See the NIHR Journals Library website for further project information

Permeability of the peroxisomal membrane: lessons from the glyoxylate cycle

Glyoxylate serves as intermediate in various metabolic pathways, although high concentrations of this metabolite are toxic to the cell. In many organisms glyoxylate is fed into the glyoxylate cycle. Enzymes participating in this metabolism are located on both sides of the peroxisomal membrane. The permeability of this membrane for small metabolites paves the way for exchange of intermediates between proteins catalyzing consecutive reactions. A model, in which soluble enzymes accumulate in close proximity to both ends of pore-like structures forming a transmembrane metabolon could explain the rapid and targeted exchange of intermediates. The metabolites passing the membrane differ between the three model organisms Saccharomyces cerevisiae, Arabidopsis thaliana, and Candida albicans, which reflects the ease of evolutionary adaptation processes whenever specific transporter proteins are not involved. The atypical permeability properties of the peroxisomal membrane together with a flexible structural arrangement ensuring the swift and selective transport across the membrane might represent the molecular basis for the functional versatility of peroxisomes

The abiotic environment of Heliamphora nutans (Sarraceniaceae): pedological and microclimatic observations on Roraima Tepui

The aim of this study was the study of the abiotic environment of the carnivorous pitcher plant Heliamphora nutans (Sarraceniaceae), including the microclimate and the geochemistry of the soil of the growing sites on Roraima Tepui and discuss their relevance within the recent model of carnivorous plant ecology. The soil was peaty and low in nutrients. The microclimate on the site was very balanced, with moderately cool temperatures, a constant high humidity and very low wind speed. Heliamphora was not exposed to any recognizable climatic stress. Previous macroclimatic measurements reflected the growth conditions of Heliamphora only incorrectly, since humidity decreased drastically with height. The apparent conflict with the common model of carnivorous plant ecology was caused by the dense surrounding vegetation. However, the leaf coverage of these non carnivorous plants was too low to cause significant insolation decrease for Heliamphora. Furthermore, the temperature regime of the pitcher fluid was more balanced than the temperature of the leaf. This may improve conditions for the growth of microorganisms in the pitcher fluid that contribute to the degredation of the plant's prey

Appendix material - are cyclic plant and animal behaviours driven by gravimetric mechanical forcing?

Appendix material to article - https://academic.oup.com/jxb/advance-article/doi/10.1093/jxb/erab462/6417250 Includes gravimetric tide data used in the manuscript

Non-contact measurement of a free flying bumblebee's (Bombus terrestris) electrical potential as it approaches and leaves a fixed electrode

With increasing evidence of electroreception in terrestrial arthropods, understanding receptor level processes is vital to appreciating the capabilities and limits of this sense. Here, we examine the spatio-temporal sensitivity of mechanoreceptive filiform hairs in detecting electrical fields. We first present empirical data, highlighting the time-varying characteristics of biological electrical signals. We then explore how electrically sensitive hairs may respond to such stimuli. The main findings are: 1) oscillatory signals (elicited by wingbeats) influence the spatial sensitivity of hairs, unveiling an inextricable spatio-temporal link; 2) wingbeat direction modulates spatial sensitivity; 3) electrical wingbeats can be approximated by sinusoidally modulated DC signals; and 4) for a moving point charge, maximum sensitivity occurs at a faster timescale than a hair's frequency-based tuning. Our results show that electro-mechanical sensory hairs may capture different spatio-temporal information, depending on an object's movement and wingbeat and in comparison, to aero-acoustic stimuli. Crucially, we suggest that electrostatic and aero-acoustic signals may provide distinguishable channels of information for arthropods. Given the pervasiveness of electric fields in nature, our results suggest further study to understand electrostatics in the ecology of arthropods and to reveal unknown ecological relationships and novel interactions between species

Bio-rhythms and gravimetric tide

Supplementary Material to articl

TideData Kanehoe-180 from_01Sep1980.csv, Appendix material - are cyclic plant and animal behaviours driven by gravimetric mechanical forces?

gravimetric tide data for Kanehoe - Hawaii/US

Supplementary material - are cyclic plant and animal behaviours driven by gravimetric mechanical forcing?

Supplement Materia

TideData LaJola-180 Oct1964.csv, Appendix material - are cyclic plant and animal behaviours driven by gravimetric mechanical forces?

gravimetric tide data for La Jola - California/US