Posterior Tibial Nerve Stimulation for the Treatment of Fecal Incontinence Following Obstetric Anal Sphincter Injury

OBJECTIVES: Obstetric anal sphincter injuries (OASI) are a major risk factor for fecal incontinence (FI). Neuromodulation is often used as second-line therapy for FI, but evidence for its efficacy is conflicting. We aimed to evaluate the efficacy and predictive factors of posterior tibial nerve stimulation for obstetric anal sphincter injury-induced FI. MATERIALS AND METHODS: Consecutive females with FI related to past OASI who had not responded to first-line therapy and had received 8-12 weeks of posterior tibial nerve stimulation were included. Subjects aged more than 50 and/or having other causes of FI were excluded. Patients underwent anorectal physiology and endoanal ultrasound pretherapy. Symptom burden was evaluated pretherapy and posttherapy using Rockwood and Wexner scales. A Wexner score reduced to below 10 or halved was used to define responders. RESULTS: A total of 37 females (mean age 38 years, median parity 2) were included. About 17 (46%) had ultrasonographically visualized anal sphincter defects and 41% had a history of third or second-degree perineal tears. About 14 subjects (38%) were deemed responders. Compared with nonresponders, responders had lower baseline rectal distension thresholds and tended to have disrupted (59%) than intact sphincters (20%, p < 0.01). Responders demonstrated improvement in Rockwood score for depression and embarrassment, visual analogue score for bowel symptoms and stool consistency (median baseline Bristol score 5, to 3 posttherapy; p < 0.01). CONCLUSIONS: Of a well-defined cohort of females with FI secondary to OASI, 38% responded to posterior tibial nerve stimulation. Much of this improvement may relate to improvement in stool consistency

Frequencies of Salmonella enterica in growing pigs in Paraguay

The objective of this study was to (1) estimate frequencies of Salmonella enterica in growing pigs and (2) investigate farmers' perception and practices towards pig farming in Central Department, Paraguay. Twelve out of 19 districts in the department were selected and 33 farms with growers in the selected districts were recruited. Questionnaire interviews for each study farm, in combination with faecal sample collections (n = 30 per farm), which were microbiologic ally examined and visual inspection of pig production facilities were performed between March and November 2009. A questionnaire was designed to obtain basic information of a farm such as the number of pigs owned and some selected farming management practices. Faecal samples were used for Salmonella isolation, using buffered peptone water to have salmonellae pre-enriched, followed by xylose lysine tergitol 4 agar and brilliant green sulfapyridine agar. Suspect colonies were bio chemically tested by triple sugar iron agar in combination with lysine iron agar to confirm the identity. The true frequency probability and associated 95% Bayesian credible intervals (95% BCI) were computed via the Gibbs sampler, a Markov chain Monte Carlo technique. Overall, 18% (95% BCI: 8-31%) of the tested 1000 faecal samples were classified as positive for Salmonella enterica. All the study farms had at least one positive sample for Salmonella enterica (frequency range: 3-60%). Apparent prevalence at farm-level was therefore 100% (one-sided 97.5% confidence limit: 89%). Twenty-eight different serovars for Salmonella enterica were found. Based on increase the number of study districts, farms as well as animals in combination with improvement of sampling methods, possible spatial differences and risk factors/indicators should be clarified by further investigations.Facultad de Ciencias Veterinaria

Frequencies of Salmonella enterica in growing pigs in Paraguay

The objective of this study was to (1) estimate frequencies of Salmonella enterica in growing pigs and (2) investigate farmers' perception and practices towards pig farming in Central Department, Paraguay. Twelve out of 19 districts in the department were selected and 33 farms with growers in the selected districts were recruited. Questionnaire interviews for each study farm, in combination with faecal sample collections (n = 30 per farm), which were microbiologic ally examined and visual inspection of pig production facilities were performed between March and November 2009. A questionnaire was designed to obtain basic information of a farm such as the number of pigs owned and some selected farming management practices. Faecal samples were used for Salmonella isolation, using buffered peptone water to have salmonellae pre-enriched, followed by xylose lysine tergitol 4 agar and brilliant green sulfapyridine agar. Suspect colonies were bio chemically tested by triple sugar iron agar in combination with lysine iron agar to confirm the identity. The true frequency probability and associated 95% Bayesian credible intervals (95% BCI) were computed via the Gibbs sampler, a Markov chain Monte Carlo technique. Overall, 18% (95% BCI: 8-31%) of the tested 1000 faecal samples were classified as positive for Salmonella enterica. All the study farms had at least one positive sample for Salmonella enterica (frequency range: 3-60%). Apparent prevalence at farm-level was therefore 100% (one-sided 97.5% confidence limit: 89%). Twenty-eight different serovars for Salmonella enterica were found. Based on increase the number of study districts, farms as well as animals in combination with improvement of sampling methods, possible spatial differences and risk factors/indicators should be clarified by further investigations.Facultad de Ciencias Veterinaria

Joint Hypermobility Syndrome Affects Response to a Low Fermentable Oligosaccharide, Disaccharide, Monosaccharide and Polyol Diet in Irritable Bowel Syndrome Patients: A Retrospective Study

Background: The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet causes significant clinical improvement in patients with irritable bowel syndrome (IBS). Joint hypermobility syndrome (JHS), defined as musculoskeletal symptoms in a hypermobile individual in the absence of systemic rheumatological disease, may be associated with functional gastrointestinal symptoms, including IBS. The aim of this study is to examine whether JHS can affect the response to the low FODMAP diet in patients with IBS. Methods: In this retrospective study, we included patients with IBS according to Rome III criteria who had followed a low FODMAP diet. Symptoms scores were measured before and after the low FODMAP diet. Results: A total of 165 patients (130 females, age 44 ± 14 years) were included. Diarrhea predominant IBS (IBS-D) was present in 40.6% of our patients while JHS was present in 21.2%. The score for abdominal pain was higher for JHS compared to non-JHS prior to intervention (P = 0.011). Symptoms improved in both groups of patients after a low FODMAP diet (P < 0.0001). The largest effects were shown with significant decreases of the average score and bloating. When broken down by JHS and IBS type, a low FODMAP diet significantly improved pain, bloating, diarrhea, constipation, and the average score with the largest effect in JHS/constipation predominant IBS (IBS-C), JHS/mixed IBS and unclassified IBS (IBS-M), JHS/IBS-D, non-JHS/IBS-C and JHS/IBS-M, respectively. Conclusions: Our study suggests that a low FODMAP diet has a greater effect on IBS symptoms in JHS than non-JHS patients

Implications of Inflammatory Bowel Disease for reconstructive surgery in non-malignant urinary tract dysfunction:an International Continence Society working group report

Potential consequences of inflammatory bowel disease (IBD) need evaluation for patients considering urinary tract reconstruction for benign disease. A working group was formed by the International Continence Society, which considered urinary tract reconstruction in IBD.Methods Nominal group technique was used to derive consensus. Principal aspects of IBD assessment and surgery decision-making were agreed. A questionnaire was used to facilitate the generation of statements by a core focus group of experts, which were modified and ratified by the wider working group. This was followed by final voting by the full working group.Results General considerations included identification importance of the specialist IBD multi-disciplinary team. Peri-operative considerations recommended avoiding pre-operative fasting from midnight and using an enhanced recovery after surgery (ERAS) protocol. Selection of bowel segment, pre-operative optimisation and post-operative issues were considered for both Ulcerative colitis (UC) and Crohn’s disease. UC is not an absolute contraindication to urinary tract reconstruction using small or large bowel. Elective reconstructive surgery should wait at least three months following resolution of any acute UC flare-up to correct all abnormalities. Crohn’s disease is a high-risk disease for urinary tract reconstruction, even if in remission. In Crohn’s, reconstructive surgical options are limited by the location and extent of gastrointestinal segment(s) affected and the phenotype of disease.Conclusion The consensus opinion indicates that urinary tract reconstruction using bowel segments is feasible in carefully selected and optimised patients with IBD lacking alternative management options, provided there is access to appropriate multidisciplinary skills. UC is relatively low risk for surgical procedures, whereas Crohn’s has considerably increased risk of morbidity. The potential risks must be properly discussed with patients considering reconstructive urological procedures. Outcomes should be carefully monitored and published to identify the safety and efficacy of reconstructive surgery in IBD, including full description of the disease status

Efficacy of Percutaneous Posterior Tibial Nerve Stimulation for the Management of Fecal Incontinence in Multiple Sclerosis: A Pilot Study

BACKGROUND: Fecal incontinence is a debilitating and highly prevalent problem among multiple sclerosis patients. Conservative therapies often fail to provide benefit. Posterior tibial nerve stimulation is a minimally invasive neuromodulatory therapy with proven efficacy for fecal incontinence in non-neurological settings. OBJECTIVE: To evaluate the efficacy of posterior tibial nerve stimulation in treating multiple sclerosis-related fecal incontinence. METHODS: Consecutive multiple sclerosis patients with fecal incontinence that had failed conservative therapy received posterior tibial nerve stimulation between 2012 and 2015. All patients had previously undergone anorectal physiology tests and endoanal ultrasound. Patients whose Wexner incontinence score reduced below 10 post-therapy or halved from baseline were deemed responders. RESULTS: Thirty-three patients (25 female, median age 43 years) were included. Twenty-three (70%) had urge, 4 (12%) passive, and 9 (27%) mixed fecal incontinence. Twenty-six (79%) were classified as responders. The majority of subjects had relapsing-remitting multiple sclerosis (67%); those had a significantly higher response rate (95% vs. 67% and 50% in primary and secondary progressive respectively, P < 0.05). Responders tended to be more symptomatic at baseline and had greater improvements in bowel symptom scores and quality of life scores with therapy. CONCLUSION: Posterior tibial nerve stimulation demonstrates potential as an effective therapy for fecal incontinence in multiple sclerosis. These findings provide the basis for future more definitive controlled studies

IGHMBP2 mutation associated with organ-specific autonomic dysfunction

Biallelic mutations in the IGHMBP2 have been associated with two distinct phenotypes: spinal muscular atrophy with respiratory distress type 1 (SMARD1) and CMT2S. We describe a patient who developed progressive muscle weakness and wasting in her upper and lower limbs from infancy. She developed respiratory involvement at age 9, eventually requiring 24-h non-invasive ventilation, and severe autonomic dysfunction restricted to the gastrointestinal tract. Neurophysiological studies at age 27 years revealed absent sensory and motor responses and severe chronic denervation changes in proximal muscles of the upper limbs. Targeted multigene panel sequencing detected a novel homozygous missense variant in the IGHMBP2 gene (c.1325A > G; p.Tyr442Cys). This variant was validated by Sanger sequencing and co-segregation analysis confirmed that both parents were asymptomatic heterozygous carriers. This case report confirms that IGHMBP2 related disorders can result in a severe peripheral neuropathy with gastrointestinal autonomic dysfunction requiring parenteral nutrition

Frequencies of Salmonella enterica in growing pigs in Paraguay

The objective of this study was to (1) estimate frequencies of Salmonella enterica in growing pigs and (2) investigate farmers' perception and practices towards pig farming in Central Department, Paraguay. Twelve out of 19 districts in the department were selected and 33 farms with growers in the selected districts were recruited. Questionnaire interviews for each study farm, in combination with faecal sample collections (n = 30 per farm), which were microbiologic ally examined and visual inspection of pig production facilities were performed between March and November 2009. A questionnaire was designed to obtain basic information of a farm such as the number of pigs owned and some selected farming management practices. Faecal samples were used for Salmonella isolation, using buffered peptone water to have salmonellae pre-enriched, followed by xylose lysine tergitol 4 agar and brilliant green sulfapyridine agar. Suspect colonies were bio chemically tested by triple sugar iron agar in combination with lysine iron agar to confirm the identity. The true frequency probability and associated 95% Bayesian credible intervals (95% BCI) were computed via the Gibbs sampler, a Markov chain Monte Carlo technique. Overall, 18% (95% BCI: 8-31%) of the tested 1000 faecal samples were classified as positive for Salmonella enterica. All the study farms had at least one positive sample for Salmonella enterica (frequency range: 3-60%). Apparent prevalence at farm-level was therefore 100% (one-sided 97.5% confidence limit: 89%). Twenty-eight different serovars for Salmonella enterica were found. Based on increase the number of study districts, farms as well as animals in combination with improvement of sampling methods, possible spatial differences and risk factors/indicators should be clarified by further investigations.Facultad de Ciencias Veterinaria

Impaired motility in Barrett's esophagus: A study using high-resolution manometry with physiologic challenge

BACKGROUND: Esophageal dysmotility may predispose to Barrett's esophagus (BE). We hypothesized that high-resolution manometry (HRM) performed with additional physiologic challenge would better delineate dysmotility in BE. METHODS: Included patients had typical reflux symptoms and underwent endoscopy, HRM with single water swallows and adjunctive testing with solids and rapid drink challenge (RDC) before ambulatory pH-impedance monitoring. BE and endoscopy-negative reflux disease (ENRD) subjects were compared against functional heartburn patient-controls (FHC). Primary outcome was incidence of HRM contractile abnormalities with standard and adjunctive swallows. Secondary outcomes included clearance measures and symptom association on pH-impedance. KEY RESULTS: Seventy-eight patients (BE 25, ENRD 27, FHC 26) were included. Water swallow contractility was reduced in both BE (median DCI 87 mm Hg/cm/s) and ENRD (442 mm Hg/cm/s) compared to FHC (602 mm Hg/cm/s; P < .001 and .04, respectively). With the challenge of solid swallows and RDC, these parameters improved in ENRD (solids = 1732 mm Hg/cm/s), becoming similar to FHC (1242 mm Hg/cm/s; P = .93), whereas abnormalities persisted in BE (818 mm Hg/cm/s; P < .01 c.f. FHC). In BE and ENRD, reflux events (67 vs 57 events/24 hour) and symptom frequency were similar; yet symptom correlation was significantly better in ENRD compared to BE, which was comparable to FHC (symptom index 30% vs 4% vs 0%, respectively). Furthermore, bolus clearance and exposure times were more pronounced in BE (P < .01). CONCLUSIONS & INFERENCES: Reduced contractile effectiveness persisted in BE with the more representative esophageal challenge of swallowing solids and free drinking; while in ENRD and FHC peristalsis usually improved, demonstrating peristaltic reserve. Furthermore, symptom association and refluxate clearance were reduced in BE. These factors may underlie BE pathogenesis