By P. Snorre. Center for Creative Studies College of Art and Design. 2019.
When a cardiovascular mechanism could be identified nolvadex 20mg discount, it was most often related to hemorrhage purchase nolvadex 20 mg on-line, transfusion purchase nolvadex 20mg visa, or inappropriate fluid therapy cheap nolvadex 20mg with visa. Respiratory mechanisms: Respiratory mechanisms included laryngospasm, airway obstruction, and difficult intubation (in decreasing order). Most patients who had airway obstruction or were difficult to intubate had other significant underlying disease. Equipment-related mechanisms: The most common equipment-related mechanisms that led to a cardiac arrest were com- plications related to attempted central venous catheterization (e. A viral infection 2 to 4 weeks before general anesthesia and endotracheal intubation appears to place the child at an increased risk for perioperative pulmonary complications, such as wheezing, laryngospasm, hypoxemia, and atelectasis. This is more likely if the child has a severe cough, high fever, or a family history of reactive airway disease. Laboratory tests: Few, if any, preoperative laboratory studies are cost effective. Some pediatric centers require no preop- erative tests in healthy children undergoing minor procedures. Most asymptomatic patients with cardiac murmurs do not have significant cardiac pathology. Consultation with a pedi- atric cardiologist should be obtained if the patient is symptomatic (e. Infants are fed breast milk up to 4 h before induction, whereas formula or liquids and a ‘light’ meal may be given up to 6–8 h before induction. These recommendations are for healthy patients without risk factors for aspiration or decreased gastric emptying. Premedication: There is great variation in the recommendations for premedication of pediatric patients. Children who appear likely to exhibit uncontrollable separation anxiety should be given a sedative, such as midazolam (0. Precordial stethoscopes provide an inexpen- sive means of monitoring heart rate, heart sounds, and airway patency. Pulse oximetry and capnography: Hypoxia from inadequate ventilation remains a common cause of perioperative morbid- ity and mortality. In neonates, the pulse oximeter probe should preferably be placed on the right hand or earlobe to measure preductal oxygen saturation. Flow-through analyzers are usually less accurate in patients weighing less than 10 kg. Invasive monitoring: Arterial cannulation and central venous catheterization demand caution. Air bubbles must be removed from pressure tubing, and small volume flushes should be used to prevent air embolism, unintended heparinization, and fluid overload. The right radial artery is often chosen for cannulation in neonates because its preductal location mirrors the oxygen content of the carotid and retinal arteries. A femoral artery catheter may be an alternative in very small neonates and left radial or right or left dorsalis pedis arteries are alternatives in infants. Urinary output is an important indicator of the adequacy of intravascular volume and cardiac output. Blood glucose monitoring: Premature or small-for-gestational age neonates and neonates receiving hyperalimentation or whose mothers have diabetes are prone to hypoglycemia and should have frequent blood glucose measurements. Awake or sedated-awake intubation with topical anesthesia should be considered for emergency procedures in neonates and small infants when they are critically ill or a potential difficult airway is present. Intravenous Induction The same induction sequence can be used as in adults: propofol followed by a nondepolarizing muscle relaxant or succinylcholine. Alternatively, intubation can be accomplished with the combination of propofol, lidocaine, and an opiate with or without an inhaled agent, avoiding the need for a muscle relaxant. The child can usually be coaxed (espe- cially after oral midazolam pretreatment) into breathing an odorless mixture of N O (70%) and O (30%). Patients typically pass through an excitement stage during which any stimulation can induce laryngospasm. Steady application of 10 cm of positive end-expiratory pressure will usually overcome laryngospasm. The saphenous vein has a consistent location at the ankle, and with experience, the practitioner can usually cannulate it even if it is not visible or palpable. Tracheal Intubation Preoxygenation: 100% O should be given before intubation to increase patient safety during the apneic period before and 2 during intubation. For awake intubations in neonates and infants, adequate preoxygenation and oxygen insufflation during laryngoscopy (e. Pediatric anatomy: Infants’ prominent occiputs tend to place the head in a flexed position before intubation. This is easily corrected by slightly elevating the shoulders with towels and placing the head on a doughnut-shaped pillow. In older children, prominent tonsillar tissue can obstruct visualization of the larynx. Straight laryngoscope blades aid intubation of the anterior larynx in neonates, infants, and young children. Correct tube size is con- firmed by easy passage into the larynx and the development of a gas leak at 15 to 20 cm H O pressure for an uncuffed tube. Airwa y Eq u ip m e n t fo r Pe d ia tric Pa tie n ts Premature Neonate Infant Toddler Small Child Large Child Ag e 0–1 month 0–1 month 1–12 months 1–3 years 3–8 years 8–12 years Weight (kg) 0. During spontaneous ventilation, even the low resistance of a circle system can become a significant obstacle for a sick neonate to overcome. Ventilation mode: The pressure-limited mode should be used for neonates, infants, and toddlers to reduce the risk of barotrauma. For children weighing less than 10 kg, adequate tidal volumes are usually achieved with peak inspiratory pressures of 15 to 18 cm H O. For larger children, the volume control mode may be used, and tidal volumes may be set at 6 to 8 mL/kg. For this reason, pediatric tubing is usually shorter and stiffer (less compliant). Anesthetic agents: Anesthesia can be maintained in pediatric patients with the same agents as in adults. Some clinicians switch to isoflurane after a sevoflurane induction hoping to reduce the likelihood of emergence agitation or postoperative delirium. Neonates may be particularly susceptible to the cardiodepressant effects of general anesthetics. Nondepolarizing muscle relaxants: Nondepolarizing muscle relaxants are often required for optimal surgical conditions; this is particularly true in neonates and sick children, who may not tolerate increased concentrations of volatile agents. A programmable infusion pump or a buret with a microdrip chamber are useful for accurate measurements. Drugs are flushed through low dead-space tubing to mini- mize unnecessary fluid administration. Maintenance: Requirements for pediatric patients can be determined by the 4:2:1 rule: 4 mL/kg/h for the first 10 kg of weight, 2 mL/kg/h for the second 10 kg, and 1 mL/kg/h for each remaining kilogram. Neonates require 6 mg/kg/min of glucose to maintain euglycemia (40–125 mg/dL); premature neonates require 6 to 8 mg/kg/min. Preoperative fluid deficits are often administered in aliquots of 50% in the first hour and 25% in the second and third hours. Large quantities of dextrose-containing solutions are avoided to prevent hyperglycemia. Replacement: Blood loss is typically replaced with non–glucose-containing crystalloid (e. Platelets and fresh- frozen plasma 10 to 15 mL/kg should be given when blood loss exceeds 1 to 2 blood volumes. One unit of platelets per 10 kg of weight raises the platelet count by about 50,000/µL. Blocks are often facilitated by ultrasound guidance or nerve stimulation (or both). Caudal anesthesia has proved useful after a variety of surgeries, including circumcision, inguinal herniorrhaphy, hypospadias repair, anal surgery, and other subumbilical procedures. Contraindications include infection around the sacral hiatus, coagulopathy, or anatomic abnormalities. If loss of resistance is used, the glass syringe should be filled with saline, not air, because of the risk of air embolism. After the “pop” that signals penetration of the sacrococcygeal membrane, the needle is lowered and advanced only a few millimeters to avoid entering the dural sac or the anterior body of the sacrum.
Ludwig E (1977) Classiﬁcation of the types of androgenic alopecia (common baldness) occurring in the female sex 20 mg nolvadex for sale. Br J Dermatol performed with the electrosurgical pencil purchase 10 mg nolvadex visa, should not be 97:247–254 performed on the small vessels of the deep dermis because 5 cheap 20 mg nolvadex with mastercard. Morestin H (1911) La réduction graduelle des difformités tégumen- the coagulation can damage the hair bulbs purchase nolvadex 10mg mastercard. Jpn J Dermatol Urol 46:135–138 A solid anatomical landmark during the dissection (that is 8. Orentreich N (1959) Autograft in alopecias and other selected performed in the Merckel space), the galea offers a protec- dermatological conditions. Juri J (1975) Use of parieto-occipital ﬂaps in the surgical treatment tive plan to the hair bulbs in the cephalic portion of the scalp. Plast Reconstr Surg 55:456–460 It guarantees, via its vessel-bearing role, vascular safety for 10. Nataf J (1984) Surgical treatment for frontal baldness: the long the ﬂaps (the supragaleal network reinforces the dermal and temporal vertical ﬂap. Nataf J (1978) Lambeaux du cuir chevelu et étude comparative avec les autres techniques de transplantation. Plast Reconstr Surg 65:42–49 The two structures that offer a mechanical resistance are the 13. Ann Plast Surg 27(5):476–487 • Permanent alopecia of the margins due to necrosis of the 19. Phase ultime du traitement par réduction de tonsure avec correction de la fente • Necrosis of the margins with healing by second intention alopécique occipitale au moyen de trios lambeaux de transposition. Tremolada C, Candiani P, Signorini M, Vigano M, Donati L (1994) References The surgical anatomy of the subcutaneous fascial system of the scalp. Facial Plast Surg Clin North Thomas, Springﬁeld Am 12:201–217 Hair Transplantation Marco Toscani and Mariangela Ciotti Nowadays hair transplantation is the most commonly used sur- at the hairline, caused an unnatural aspect known as a “doll’s gical technique to treat androgenetic alopecia. The Donor sites healed by second intention caused cicatricial result can be appreciated only after a few months when the thinning with large wastage of bulbs, which compelled grafted bulbs have regenerated hair, and limited density may patients to wear long hair or undergo further operations to require further operations to achieve the desired effect. For these reasons the technique Relative contraindications are advanced or very young became rather unpopular. Since the 1990s, with the assistance of new microsurgical 1 Historical Background instruments, magnifying glasses, and microscopes for hair- follicle dissection, transplantation with mini- and micrografts The theory of “donor dominance” arose after the publication of has been carried out worldwide with natural-appearing results. Orentreich’s observations regarding the autotransplant method Microscopic studies on hair growth patterns revealed that in 1959. This theory states that grafted bulbs continue to show hair naturally grows in clusters of 1–4 hairs, leading to the the characteristics of the donor site, i. Consequently, dissection after they have been transplanted to different sites . For instance, punches were connected to the handle of a The number of grafts inserted at each session varies dental micromotor to allow harvesting of multiple grafts in a according to the surgeon and the patient. The caliber was restricted to 5 mm, as bigger area, the number of the grafts used and the density of implant grafts would cause central avascular necrosis and lead the is in inverse proportion to their diameter. Such drugs can alter blood coagulation and cause excessive bleeding during surgery. Alcohol slows blood coagulation, causes vasodilation, and can make the whole procedure more difﬁcult Do not take vitamin E or B complex 7 days before surgery: these vitamins can slow blood coagulation In order to improve blood coagulation, take vials of tranexamic acid diluted in half a glass of water twice a day, 1 week before surgery Wash your hair the morning of surgery. Do not use hair products such as mousse, gel, etc Do not cut your hair in the posterior part of your head before surgery. If possible, let your hair grow longer Drink many liquids and have a light meal the night before surgery Avoid caffeine the morning of surgery: relaxing drugs that cannot be taken with caffeine will be administered during surgery Do not eat at least 5 h before surgery Wear comfortable clothes, large trousers, button-up shirt, bring a baseball cap, a bandana or something similar to wear after surgery to go home N. Local anesthetics, sedatives, and other drugs are usually administered during surgery and may remain in the circulation for some hours after the operation, therefore we recommend that the patient is accompanied and avoids driving 2 Description of the Surgical Operation • On the patient’s arrival the analyses are checked, the con- sent form is signed, and preoperative photos are taken • The patient is introduced to the surgical team • One tablet of clonidine, 150 mg (Catapres) is adminis- tered almost an hour before surgery as antihypertensive and mild sedative • The markings of the area to be transplanted are carried out as previously agreed with the patient Hairline design: – Regarding hairline design, the concepts described in general principles are valid; it is good practice to ask the patient to bring a photo taken some years before the hair loss to recreate, if possible, the original hair- line; this request is always appreciated by the patients. Moreover, after marking the hairline, possibly in front of a mirror to make sure that the patient agrees, small irregularities and cusps are created to obtain a F i g. The size of some basic principles: the strip should be calculated according to the require- – Considering that androgenetic alopecia is a progres- ments, including a small percentage of excessive tis- sive and often unpredictable disease, especially in sue, with consideration of the possible waste that may young patients, it is important to envision the pos- occur during dissection. The harvest is facilitated by positioning the patient prone – An antiseptic agent is then applied to the whole scalp. Technical – To reduce perioperative bleeding variations basically concern: We generally use a cold (+4 °C) 2 % solution con- taining 2 % lidocaine or 2 % mepivacaine with • Use of a single-bladed scalpel 1:80. It is permissible to add a it damages a greater number of bulbs at the donor site. We use a #10 blade and go as deep as We use ﬁne needles of 27 or 30 gauge, and progres- necessary to harvest the hair follicles without damaging the sively inﬁltrate the entire surgical area in a double vasculo-nervous structures underneath. This is also performed in The hemostasis of the donor site must be focused on a double layer above and below the galea (epigaleal and galeal vessels, paying special attention to avoid damaging subgaleal) and allows a pressure ischemia (because of the the bulbs in the subcutaneous layer with heat from the elec- injected liquid) and a vasoconstriction (because of trosurgical pencil. Moreover, it reduces the possibility of The closure may sometimes require minimal detachment to damaging subgaleal vessels and nerves at the donor site allow the wound margins to adapt, although in cases of second- by moving them away from the incision point. These authors maintain that by de-epithelializing one of the mar- gins the hair will grow through the scar, making it less linear Fig. The suture can be performed in two layers with deep absorbable sutures, or in a single layer with a 3-4/0 nylon running suture. Metal clips, as used by several authors, lead 10–12 months between the procedures to allow the scalp to to a more painful postoperative course (Fig. In secondary procedures it is common for expert surgeons to perform the removal of the previous scar tissue by includ- ing it in the strip, so that the patient has a single ﬁnal scar. To avoid this, the surgron is recom- and must pay due consideration to the bulbs, which are pre- mended to perform proper detachment of the margins, care- vented from drying by dipping them into low-temperature fully suture the subcutaneous tissue, and allow at least 0. These segments are then cut with the help of the micro- scope or microsurgical loop. According to the needs of the • Frustule (punch, trephine): This technique consists in the recipient area it is possible to obtain: monobulbar micro- removal from the donor area of a cylinder of scalp to sub- grafts with a single hair; micrografts of 1–1. The grafts are then counted and aligned, for all surgeons’ needs, such as the lanceolate needle, according to their size, on wet gauze in a Petri dish (Fig. To achieve doned because it led to greater local damage and slower more effective anesthesia in the frontal region, it is possible growth of the grafted hairs . However, we have abandoned this a the natural direction of the hair growth, with an anterior technique because the minimal advantage is offset by the risk direction and an attachment angle of around 30–45° in the of injuring nearby vessels, creating signiﬁcant and irritating frontal and anterior region and 15–20° downward in the lat- periocular ecchymosis. Regarding the tumescence with cold adrenalinated The dimension of the incisions in the recipient sites sodium chloride in this area, surgeons’ opinions are divided. Once posi- Although some prefer not to perform it to avoid the excessive tioned, the grafts are kept in place by the pressure created by 544 M. When nishes the hairline with a gradual effect and avoids the all of the grafts are in place, the last check is carried out doll’s-head effect that occurs when oversized grafts are before dressing the wound. A rule of thumb in the design of the hairline is to create some cusps to make it irregular, as it would appear natu- 6 Tips and Suggestions rally, while in the crown area the incisions should be ori- ented by following the natural vortex or, if absent, by In the frontal region, to obtain natural results we recommend recreating it. Some surgeons prefer making the incision and immediately inserting the graft in the recipient site while the needle (or the blade) is pulled out (stick-and-place technique) . This technique allows bet- ter control of the possible bleeding, even if less precise because it does not allow prior estimation of the number of grafts to be inserted or a comprehensive view of the remain- ing work. The graft insertion phase is delicate because the posi- tive outcome of the operation greatly depends on it. It is important to carefully choose the hairs to be inserted, pay- ing attention to place in the frontline the thinnest monobul- bar hairs and then gradually thicker monobulbar hairs, all in the correct orientation. These criteria should be espe- cially respected in patients with black or dark hair and white complexion; in patients with white, grizzled, or fair hair it is possible to insert some bibulbar grafts in the frontline as well. In hair density-increasing procedures and in women, in whom the hairline is preserved, the insertion of monobul- bar grafts would not confer the required density; therefore, we suggest directly using the follicular units with 3–4 hairs or even bigger grafts in cases of very light or grizzled Fig. The application of products such as For every graft, we suggest to always check the depth of minoxidil seems to reduce the thinning and to speed the implant: a graft that is too superﬁcial tends to come out (tent- growth of new hair. Although this is the normal time frame for hair growth, every Finally, it is important to check the correct orientation of patient can react in a different manner: for some patients the the grafts in the recipient site as described by the general hair growth begins earlier, for others later. With the passing of time, other hair will grow and become thicker, longer, and darker. After sur- gery the patient may feel an itch in the grafted area or reduced 7 Dressing sensibility in the donor area, but such symptoms tend to dis- appear within a few months. In the absence of bleeding, the head may be left free of dress- The incision in the donor area is perfectly healed, but the ing.
Though small generic 10 mg nolvadex visa, this reduction was enough to change the diagnostic categorization of one-third of their subjects purchase 20mg nolvadex with visa. Normal Female Urine Flow Rates Female urine flow rates are higher than those of men [10 cheap 10 mg nolvadex,15 discount nolvadex 10 mg on-line,24]. The other study  was limited to the effect of final urodynamic diagnosis on urine flow rates. Three studies indicated that symptomatic women had slower urine flow rates than normal women with one study  showing no difference. The flow data for these women were converted to centiles from the Liverpool Nomograms for the following analyses of their median values: A Comparison of the Urine Flow Rates of Symptomatic and Asymptomatic Women Table 53. There was a close agreement between the studies with the 1990 study  performed in a different country to the 1995 study . Effect of the Presence of Genital Prolapse on Urine Flow Rates in Symptomatic Women A generally progressive decline in the maximum and average urine flow rates (median centiles) of symptomatic women  with increasing grades of genital prolapse was noted. The most significant decline occurred in the presence of uterine prolapse closely followed by cystocoele and enterocoele. More recent data , however, would suggest the significance of this may be lost in multivariate analysis of a much larger cohort of symptomatic women. The flow rates for those symptomatic women without prior hysterectomy was found to be the same as that for the asymptomatic female population. Further analysis suggests that in women with both prior hysterectomy and intercurrent genital prolapse, there is a cumulative decline in urine flow. More recent data , however, would suggest the significance of this may be lost in multivariate analysis of a much larger cohort of symptomatic women. Effect of Age and Parity on Urine Flow Rates in Symptomatic Women Unlike asymptomatic women, there is a significant effect of age on the maximum and average urine flow rates [30,31]. More recent data  suggest that age is the main association of abnormally slow urine flow rates in a large cohort of symptomatic women. Parity was not found to be a significant factor in either this or the 1999 study . Effect of Final Urodynamic Diagnosis on the Urine Flow Rates of Symptomatic Women Median urine flow rate centiles of the urogynecology patients separated according to the final urodynamic diagnosis are given in Table 53. All categories of diagnoses have their median centiles under those for the normal female population (50 by definition). The situation during voiding is the antithesis of the situation required for continence. Continence depends on intraurethral pressure being higher than intravesical pressure. Einhorning  and later Asmusen and Ulmsten  showed clearly that before any rise in intravesical pressure, a fall in intraurethral pressure occurred. This suggests that the urethra actively relaxes during voiding rather than being passively “blown open” by the detrusor contraction. Soon after the urethra has relaxed and pelvic floor descent has occurred, the detrusor contracts. The detrusor normally contrives to contract until the bladder is empty, producing a continuous flow curve. Many women void by urethral relaxation alone with minimal or no detrusor involvement. Some women appear to void entirely 841 by increasing intra-abdominal pressure, that is, by contraction of the diaphragm and anterior abdominal wall muscles. It follows from this discussion that the urine flow may differ from normal as a result of abnormalities of the urethra or the detrusor. Urethral Factors Anatomical factors The urethra may be abnormally narrow or the urethra may not be straight. The narrowest part of the urethra, as shown by video studies of voiding, is usually the midzone. However, the urethra may become narrowed and the most common site is at the external meatus associated with estrogen deficiency in the postmenopausal women. Bladder neck obstruction in the female had been thought to be extremely rare . The female urethra is usually straight, and deviation from this state is most common in anterior vaginal wall prolapse and higher degrees of uterine and vaginal vault prolapse. Data earlier point to a possible adverse effect of such prolapse on urine flow rates. The prolapse and urethral effects make bladder outflow obstruction not that uncommon in women. Pathological Factors Unusual congenital conditions such as urethral duplications, urethral diverticula, or urethral cysts may obstruct voiding. Infective lesions as in urethritis or infected paraurethral cysts may lead to voiding difficulties. Intravaginal abnormalities, such as prolapse or foreign bodies, may also obstruct micturition. Functional Factors Abnormal urethral behavior during voiding may lead to alteration in the urine flow rate recording. Urethral closure may be due to contraction of the intraurethral striated muscle or to contraction of the pelvic floor. In the neurologically abnormal patient, contraction of the intraurethral striated muscle with or without the pelvic floor is known as detrusor sphincter dyssynergia. In the nervous and anxious but neurologically normal patient, the urethra may be closed by pelvic floor contraction. Detrusor Factors Contractility It is well known that when neurological disease occurs, bladder behavior may be altered. However, in patients with no neurological disease, poor detrusor contractility may be responsible for a slow flow rate. These patients have normal urethral function as judged by urethral pressure profilometry or radiology. Their reduced flow rates are secondary to a weak and poorly sustained detrusor contraction. A proportion of this clinical group goes on to demonstrate 842 classical neurological diseases such as multiple sclerosis. Bladder contractions are preserved if the sacral reflex arc is intact even when the upper motor neurons are damaged. However, if the sacral reflex arc is damaged, bladder contractions are generally absent. The only form of contractile activity possible when the lower motor neuron is damaged is locally mediated—the “autonomous” bladder. The urine flow rates produced by the abnormally innervated bladder are usually reduced and interrupted. Pathological Factors Although little specific literature on the subject exists, it is evident that gross disease of the detrusor will result in abnormal urine flow rates. Because flow curves cannot be numerically represented (except by urine flow rates), they are less useful for clinical comparisons than flow rates. Maximum flow rate, somewhere between the 5th and 25th centile, occurs early, and then the flow trails off. It is manifested by irregular moderately fast accelerations in maximum urine flow. Abnormal–Continuous Flow Urine flow curves reflected in flow rates below the 5th centile may generally be regarded as abnormal; abnormality can be suspected in those curves with flow rates between the 5th and 10th centile. A reduced flow rate may be due either to a urethral obstruction or to a poor detrusor contraction (Figure 53. It is necessary to perform full pressure flow studies to demonstrate the cause of a reduced urine flow rate. Characteristically, the rate of change of flow rate is rapid, indicating sphincter closure. The fluctuations 844 due to detrusor underactivity would be much slower than those seen here.
Initiation and termination of intra-right atrial reentry can be accomplished by stimuli from the right (Fig 10 mg nolvadex visa. The mechanisms by which these tachycardias are terminated is unclear cheap 20 mg nolvadex amex, but the right atrial location suggests some role of the muscarinic or adenosine receptors either directly (on K+ channels) or indirectly via adenyl cyclase nolvadex 10 mg sale. These arrhythmias must be distinguished from atrial tachycardias due to triggered activity which are typically able to be terminated by vagal maneuvers and adenosine generic nolvadex 10mg otc. Atrioventricular conduction delay and/or block may or may not precede or be associated with tachycardia termination. No large studies have been conducted to systematically determine the effect of pharmacologic manipulation on intra-atrial reentrant arrhythmias. However, intravenous verapamil, digitalis, amiodarone, and beta blockers can terminate these arrhythmias. In my experience approximately one-third of tachycardias distant from the sinus node respond to these agents. There is some disagreement in the literature about responsiveness of intra-atrial reentry to pharmacologic and physiologic maneuvers. This may not represent its frequency in the general population, but may represent the fact that automatic atrial tachycardia is persistent and less easily treated than other atrial tachycardia mechanisms. As a consequence, it is more symptomatic so it is more often referred for electrophysiologic evaluation. Automatic atrial tachycardia tends to be either chronic and persistent or transient and related to specific events. In hospitalized patients, the most common form of automatic atrial tachycardia is transient. This is most often associated with myocardial infarction, exacerbation of chronic lung disease, especially with acute infection, alcohol ingestion, and a variety of metabolic derangements (e. Because most hospitalized patients with automatic atrial tachycardia are severely ill, the studies of automatic atrial tachycardia have only been performed in incessant and chronic cases. Incessant automatic atrial tachycardia is a not uncommon clinical problem in children and is being recognized more frequently in adults. However, the rates of automatic atrial tachycardias are influenced significantly by endogenous catecholamines and can go from 100 bpm at rest to greater than 250 bpm on exercise. Such tachycardias, when present for long periods of time, can lead to a reversible tachycardia-mediated cardiomyopathy. Because the rhythm is initiated by enhanced automaticity of a single focus, the first and subsequent P-wave and atrial activation sequences are identical. The atrial activation sequence during automatic atrial tachycardia depends on the site of the automatic focus but always differs from normal sinus rhythm. The most common sites of origin of automatic tachycardias are along the crista terminalis, the atrial appendages, the triangle of Koch, the pulmonary veins, and the coronary sinus. Most early sites exhibit multicomponent electrograms suggesting poor coupling in the region of enhanced impulse formation. Whether or not the uncoupling is necessary to allow automaticity to occur is unknown. Examples of an atrial tachycardia arising from the crista terminalis and the os of the coronary sinus are shown in Figures 8-150 and 8-151. The P-R and A-H intervals during automatic atrial tachycardia are directly related to the rate of the tachycardia; the faster the rate, the longer the intervals. However, in the majority of our patients (particularly with atrial tachycardias localized to the crista and the low atrial septum) adenosine produces transient slowing of the atrial tachycardia, but does not terminate it (Fig. Of all the pharmacologic agents only beta blockers have been useful in transient cases. Incessant atrial tachycardia responds poorly to antiarrhythmic agents and therapy is either a curative ablation (see Chapter 15) or rate control. Marked prolongation of the H-V interval, however, may alter the cycle at which bundle branch block first developed. The P-wave morphology differs from sinus, as does the atrial activation sequence (dotted lines, B). The initial and subsequent P waves have the same morphology and atrial activation sequence. The effects of stimulation during automatic atrial tachycardia are similar to those reported for other automatic tissues (e. One of the hallmarks of automaticity in normally polarized tissue is that pacing produces overdrive suppression. Abnormal automaticity in depolarized tissue may not exhibit overdrive suppression. There is a gradual shortening of the tachycardia cycle length followed by a pause in repetitive cycles consistent with exit Wenckebach from that focus. In my experience, this disorder is almost universally observed in young women, many of them in the medical field. These patients complain of palpitations in response to minimal exertion, excitement, and, in particular, stress. Although these patients manifest symptoms suggestive of autonomic dysfunction, the exact mechanism of the tachycardia and symptoms is poorly understood. Although there was no significant difference in autonomic tone from controls, based on heart rate variability, in the supine and upright position these patients exhibit decreased cardiovagal responses, beta-adrenergic hypersensitivity, and a high intrinsic heart rate. However at night they typically show a decreased heart rate, albeit higher than normals, suggesting some presence of vagal tone pharmacologic therapy is usually ineffective. Radiofrequency ablation of the sinus node has been effective in the short term, but has a high (70%) recurrence rate and limited effect on symptoms. Atrial Tachycardia Due to Triggered Activity Atrial tachycardia due to triggered activity is rare in the outpatient in the absence of digitalis intoxication. Most frequently, triggered atrial tachycardias occur during exercise, during acute illnesses associated with excess catecholamines, or in response to the use of adrenergic agents (e. These arrhythmias characteristically can be initiated and terminated by programmed stimulation. Rapid pacing is more effective than timed extrastimuli for both initiation and termination. While atrial pacing is the easiest method occasionally ventricular pacing with one-to-one retrograde conduction can initiate a triggered atrial tachycardia (Fig. The cellular calcium overload leads to development of a transient inward current that produces the delayed afterdepolarizations responsible for the tachycardia. Monophasic action potential recordings can be used to detect afterdepolarizations, but care must be taken to exclude artifact. The response of the arrhythmias to programmed stimulation is often characteristic. As shown in Figure 8-159 overdrive pacing produces acceleration of the tachycardia and a shortening of the interval to the first beat of the tachycardia and the paced cycle length is decreased. Since the A-V junction and ventricles are not required for atrial tachycardias, ventricular stimulation provides a relatively simple method to distinguish the two types of arrhythmias. Since the atrium must be depolarized to reset an atrial tachycardia, upon cessation of pacing there will be a V-A-A-V response (Figs. Termination of the tachycardia in the absence of an A, rules out atrial tachycardia. In addition, single complexes of one form of reentry may initiate sustained arrhythmias of a different variety. The development of A-V nodal block, which terminated the A-V nodal tachycardia, allowed the sinus node reentry to become manifested. Atrioventricular nodal reentry has been observed in patients with bypass tracts, and multiple mechanisms of arrhythmias may be present when multiple bypass tracts are present. This may be related to the high incidence of dual A-V nodal pathways observed in such patients. Although this is most common in the Wolff–Parkinson–White syndrome during circus movement tachycardia (see Chapter 10), we have seen atrial flutter and/or fibrillation develop in the P. Upon cessation of pacing there is a V-A-A-V response with the appearance of a right atrial tachycardia.
This estimate for fecal incontinence is conservative discount nolvadex 20mg on-line, as it did not inquire about incontinence of flatus that is probably more common and has been reported to be as high as 29% at 9 months after delivery in one study of 349 primiparous women  buy nolvadex 20mg amex. Fecal incontinence is especially common after anal sphincter rupture cheap nolvadex 10 mg free shipping, with a reported prevalence of 16%–47%  nolvadex 10 mg overnight delivery. At 2–4 years postpartum, 42% of the 94 women in their study had anal incontinence, 32% had urinary incontinence, and 18% had both urinary and anal incontinence. Despite the high number of women with incontinence, only a few had sought medical advice. Changes in the Anal Canal and Pelvic Floor Related to Anal Incontinence The etiology of postpartum anal incontinence is complex and both nerve and mechanical trauma have been implicated. Nerve Damage Denervation injury of the pelvic floor may occur from traction and straining during vaginal delivery, similar to the mechanism of nerve damage reported in patients with chronic constipation, which may result in anorectal incontinence . In 80% of women with idiopathic anorectal incontinence, there is histological evidence of denervation of the striated pelvic floor muscle, particularly the puborectalis and external anal sphincter muscles . Serial measurements of pudendal nerve terminal motor latencies in patients with idiopathic anorectal incontinence show progressive damage from recurrent stretch injury during straining at stool . Denervation injuries of the pubococcygeus and external sphincter muscles have been reported after 42%–80% of vaginal deliveries [12,13]. The presence of neuropathy has been found to be related to the length of the second stage of labor, size of the baby, and instrumental delivery . However, no relationship between abnormal neurophysiology and symptoms of anal incontinence was shown. These allow the detection of differences in touch, temperature, and pain in the anal canal. The rectum has a configuration of nerve plexuses that serve as specialized sensory receptors for distension for perception of fullness, urgency to defecate, and pain [94,95]. It is believed that sensory information is critical to the preservation of continence, and in patients with fecal incontinence, there is a significant reduction in the ability to perceive electrical and other forms of stimulation . In pregnancy, however, the role of anal sensation is unclear as deficits in anal canal sensation appear to be transient and unrelated to the development of incontinence . The use of anal endosonography has enabled accurate visualization of the sphincters, thus providing strong direct evidence of the much higher incidence of previously unrecognized occult anal sphincter trauma after delivery and its importance in the pathophysiology of anal incontinence  (Figures 58. The external sphincter appears hyperechoic surrounding the hypoechoic external sphincter. Thirty-two women had new abnormal postnatal findings (defects on endosonography or prolonged pudendal nerve terminal motor latencies). Ten of the 79 primiparous women (13%) and 11 of the 48 multiparous women (23%) who delivered vaginally had anal incontinence or fecal urgency when studied 6 weeks after delivery. Twenty-eight of the 79 primiparous women (35%) had a sphincter defect on endosonography at 6 weeks; the defect persisted in all 22 women studied at 6 months. Of the 48 multiparous women, 19 (40%) had a sphincter defect before delivery and 21 (44%) afterward. The use of forceps was the single independent factor associated with anal sphincter damage, and there was a strong correlation with the presence of defects and the development of symptoms. This suggests that it is the first vaginal delivery that is the most important factor for damage to the anal sphincters. One criticism of this paper was the lack of blinding, and other authors have demonstrated that symptoms do not always correlate with ultrasound findings . Forceps delivery results in more traumas to the anal sphincters and is associated with a higher incidence of defecatory symptoms than a ventouse delivery. Subsequent studies have looked at the incidence of anal sphincter injury using endoanal ultrasound, and meta-analysis of five of these studies reveals a 26. The use of midline episiotomies, favored in the United States, has been strongly associated with a 50-fold increased risk of a third-degree tear . Studies have demonstrated that there is little attention and much imprecision with regard to the angle of incision of mediolateral episiotomy . The degree of anal sphincter trauma may also be related to occurrence of symptoms. A questionnaire study of 208 women, 13 years after vaginal delivery, found that 25% of women after fourth-degree tears and 11. In another American study  of 2858 primiparous women delivered vaginally, 19% were known to have sustained third- or fourth-degree tears. Although this study was limited in that it was questionnaire based and retrospective, it highlighted the high prevalence of anal sphincter tears possible, a reflection of the practice of midline episiotomy performed in the United States. The incidence of worse bowel control was 10 times higher in those with fourth-degree lacerations versus third-degree lacerations, which is not surprising as both internal and external sphincters are then compromised and as such cannot compensate so easily for the loss of function in the other. The urgency associated with internal sphincter damage may also exacerbate loss of bowel control to a greater degree. Another observation was that more than 50% reported new onset urinary incontinence indicating that similar risk factors pertaining to anal sphincter trauma may relate to damage and loss of function of the urethral continence mechanism. There may also be an inherent predisposition to anal sphincter trauma as there are racial differences in incidence, with the incidence of trauma greater in Asian women versus white women versus with black women having a lower incidence. This suggests that there are anatomical or physiological predisposing factors . Further evidence of genetic predisposition due to tissue types comes from a telephone survey of women who had undergone an instrumental delivery. This study reported that those with a history of joint hypermobility (a marker for collagen weakness) had an increased risk of 924 postpartum anal incontinence . Despite obvious injury to the anal sphincters, symptoms of anal incontinence may not occur for some time after delivery, and in women who experienced transient anal incontinence after a complete tear, 39% had a relapse of symptoms after the next vaginal delivery. Full-thickness anal sphincter disruption was the most significant risk factor in the development of fecal incontinence after a second vaginal delivery. However, other smaller studies have shown no significant change in anal incontinence or anal physiology in the short term for women with a previous obstetric anal sphincter injury following a subsequent birth . Although the etiology of genital prolapse is multifactorial, childbirth has been implicated as a major contributing factor. It is far more common in parous women, with 50% of parous women having some degree of genital prolapse, of which 10%–20% are symptomatic. In contrast, only 2% of symptomatic prolapse is found to occur in nulliparous women. Pathological and electrophysiological studies have shown that significant pelvic nerve denervation and reinnervation are associated with stress incontinence and prolapse. However, there are also collagenous changes in the pelvic floor, which are related to ageing, childbirth, and endogenous hormone changes, which may also predispose to prolapse and stress incontinence . During vaginal delivery, the combination of distension and stretching of the pelvic floor by both the fetal head and increase in pressure due to maternal expulsive efforts may lead to functional and anatomic alterations in the muscles, nerves, and the connective tissue of the pelvic floor and anal canal. Trauma to the pelvic floor may also lead to repair with weaker collagen and so predispose to incontinence and prolapse. These studies suggest that both pregnancy and delivery are important etiological factors for the development of pelvic organ prolapse. Changes in the levator hiatus have been shown to be related to urogenital prolapse, and surgery for prolapse has been associated with a reduction in the size of the urogenital hiatus . This suggests that a more distensible levator hiatus is associated with risk of pelvic organ prolapse. In one study  comparing nulliparous women and women after their first vaginal birth, 20% of primiparous women had a visible defect in the pubovisceral or iliococcygeal portion of the levator ani muscle. Those women with urinary incontinence were more likely to have a defect in the levator muscle. In another study, it was noted that increasing levator trauma was found in those with a longer second stage of labor. These defects are thought to be either due to avulsion of the muscles from their origin or as a result of denervation. However, whatever the possible mechanism, it is clear that such damage to the levator “plate” leads to a decrease in muscular supports to the pelvic organs and an increase on the load carried by the connective tissue and fascia. These injuries may themselves relate to stress incontinence or predispose to weakening of fascial and connective tissue supports resulting in stress incontinence. Pelvic floor ultrasound has been an increasingly useful tool for revealing changes in the levator anatomy related to parity. These defects are associated with symptoms of pelvic organ prolapse and obstructed defecation (Figures 58. In another study by this group, vaginal delivery was noted to be associated with avulsion of the levator ani from the pelvic side wall in one-third of women. On the right, there is a rectocele, with a depth of about 2 cm, filled with stool.
Ann Surg 248(4):666–674 Pertsemlidis D (1995) Minimal-access versus open adrenalectomy buy generic nolvadex 20 mg line. Surg Endosc 9(4): 384–386 Prager G order nolvadex 20mg with amex, Heinz-Peer G cheap 20 mg nolvadex overnight delivery, Passler C 20mg nolvadex amex, Kaczirek K, Scheuba C, Niederle B (2004) Applicability of laparoscopic adrenalectomy in a prospective study in 150 consecutive patients. In this regard, we have identifed a special trocar placement technique that takes this concept into consider- ation. If the distance is greater than 25 cm, we recommend using the advanced trocar placement. This technique uses two sets of trocars, with the frst set of triangulated trocars focused on the creation of jejunojejunostomy, and the second set placed cephalad to the frst to perform the gastric part of the operation, as depicted in Fig. These patients need to lose 5% of their weight preoperatively to decrease the amount of intra- abdominal fat. There are four areas affected by weight loss: the omentum, the falciform ligament, the perigastric fat and last and most importantly, the liver. A fatty liver in a patient who has not lost weight will cover the stomach and make it very diffcult to access the angle of His and staple the stomach safely (Fig. One should avoid plac- ing trocars on or inferior to this fold, as it makes the operation more diffcult. C camera; B left hand of sur- geon; E right hand of surgeon; D trocar for assistant; A liver retractor. B, C, D moved to B2, C2, D2 (B and B2, left hand of surgeon; C and C2, camera port; D and D2, right hand of surgeon) Laparoscopic Roux-en-Y Gastric Bypass 217 Fig. B = after signifcant preoperative weight loss, the fatty liver “shrinks” Patient Positioning The patient is placed in the supine position with both arms out. Care must be taken not to extend the arms excessively to prevent brachial plexus injury. The beds should be special- ized for bariatric patients with a footboard to avoid sliding during the procedure, espe- cially in steep reverse Trendelenberg. Padding is very important secondary to the increased weight of the patient on pressure points. A Foley catheter is placed and an orogastric tube is inserted by the anesthesiologist, which will be removed prior to stapling the stomach. Technique The surgeon stands on the right of the patient, the camera assistant stands behind him, and the frst assistant is on the opposite (left) side of the patient. Once the optiview trocar is in place, the right and left hand of the surgeon’s ports are placed in a double triangulated fashion, as described in Chap. This same trocar will be used by the right hand of the surgeon during the gastric part of the operation. In case of diffculties, two 5-mm trocars are inserted for the assistant on the left side. The next step is division of the greater omentum, which is performed using the harmonic shears. This reduces the distance the alimentary loop must travel to reach the stomach (Fig. Once the greater omentum is divided, clips are placed at the division to mark the site where the jejunal loop will be placed on the colon. The area of division of small bowel is identifed approximately 20–25 cm from the angle of Treitz. The next step is coagulation of any bleeding along the cut edges of the mesentery. It is extremely important to use electrocautery or clips to avoid postoperative bleeding. The harmonic shears are used to open up the crotch of this divi- sion to further extend the length of the alimentary loop. Occasionally, the proximal part of the Roux limb becomes ischemic due to stapling of the feeding vessels. The proximal part of the cut intestine is marked using several clips placed along the staple line to avoid confusion when pulling the roux limb up. A clip is placed distally, and the smallest possible opening is made using the harmonic shears (Fig. Stabilization of the stapler is performed using the stapler nearly closed to avoid widening the opening (Fig. One Kaiser stitch – named after one of our attendings – is placed at the lower part of the enterotomy (Fig. The mesenteric window is closed using a running 3–0 nonabsorbable suture, minimizing the risk of internal hernias (Fig. At this point, attention is directed to the second part of the operation (con- struction of the gastric pouch) (Fig. The proximal corener is closed using one interrupted stitch (the “Kaiser” stitch) Laparoscopic Roux-en-Y Gastric Bypass 223 Fig. Mandatory preoperative weight loss will reduce the volume of a fatty liver, which enhances and eases the use of sophisticated instruments in all cases. The angle of His is identifed to the left side of the fat pad and opened gently with the harmonic shears. The harmonic shears are used to open the lesser omentum close to the gastric wall. With the assistance of two graspers, the lesser sac is opened promptly without further dissection with the harmonic shears to minimize the risk of burn injury to the gastric wall (Fig. It is very impor- tant to avoid a fold during the frst vertical fring at the intersection between the horizontal and vertical staple lines; such a fold can create a weak point, and is frequently the site of staple line disruption, especially when stapling the thick stomach of a male patient. Laparoscopic Roux-en-Y Gastric Bypass 225 Right margin of stomach under pars flaccida Pylorus Fig. Cutting this tis- sue can result in a leak from this corner, and convert the angle of His to the angle of sorrow. Although it seems like a waste of a staple load, this tissue should also be divided with a stapler to make sure that there is no opening at the corner. Sometimes, after com- plete division of the stomach, there is a sharp angle at the corner of the pouch that can look dusky. In men, we often avoid using Seamguards due Laparoscopic Roux-en-Y Gastric Bypass 227 Fig. Arrows indicate the necessity of fring a fnal load beyond the visible staple line to avoid inadvertent opening leading to leaks to the thickness of the stomach to avoid the disruption of the staple line. Extreme attention must be paid not to twist the long Roux limb during this part of the operation. If the Roux limb looks short and the anastomosis is under tension, there are a few tricks to fx the problem. If the limb is still short, the patient should be placed back in the supine position, and the peritoneum covering the crotch of the divided mesentery should be opened. It is also possible to score the mesentery with the harmonic shears in a radiating fashion; this will ease the tension on the Roux-en-Y by lengthening it (Fig. If the length is still insuffcient, then one can divide the lesser omentum all the way up to the right crus of the diaphragm to release the attachments of the esophagus and add to the length of the pouch (Dr. Alternatively, the anastomosis can be performed in a retrocolic, retrogastric fashion, which traverses a shorter distance than the antecolic technique, but we have not needed to use this. The patient is then placed in reverse Trendelenberg position, and the gastro- jejunostomy is performed. This technique has dramatically reduced the number of postoperative strictures due to the creation of a larger anastomosis (Fig. The enterotomy and gastrostomy are completed using the harmonic shears to a length of 1. If there is a little bleeding on the mucosa, it is possible to control it with intraluminal clips. Scoring the mesentery (dotted lines) will increase the length of the Roux-en-Y by 2–3 cm Phrenoesophageal membrane Fig. This will increase the size of the gastrojejunostomy, thus reducing the risk of postoperative stricture Fig. The use of vicryl is tricky, and one should always be careful, since Vicryl can unravel. Fibrin sealant is applied on the vertical gastric stapled lines and in Petersen’s space (Figs. In case of bleeding from port sites, a spatula is used to achieve homeo- stasis from inside the abdomen, or it is inserted through the trocar site, and hemostasis completed from the outside. The patient is urged to ambulate the same day, and will be placed on a liquid diet the next morning.
Stimulation should be in an area that is acceptable and not embarrassing for patients safe nolvadex 20mg. Afferent and efferent fibers from these segmental sacral roots merge in the periphery outside the spinal cord buy nolvadex 10 mg on-line. After merging purchase 10mg nolvadex with amex, the nerve fibers continue as combined nerves that have lost their segmental innervation pattern buy discount nolvadex 10mg on-line. Peripheral neuromodulation of the lower urinary tract has been attempted via stimulation of those nerves that are related or involved in pelvic organ innervation. Peripheral neuromodulation can also be done via the overlying skin or by stimulating the dermatomes that are innervated by the same nerve as the ones that innervate the lower urinary tract. With this technique, developed in China over 5000 years ago, the “energetic harmony” of the urogenital tract might be restored by way of stimulation of specific points. Wilhelmus ten Rhyne (1647–1700) was a Dutch physician who was employed by the Dutch East India Company in 1673 where he encountered eastern traditional medicine. In 1683 he published a book entitled Dissertatio de Arthritide: Mantissa Schematica: De Acupunctura: Et Orationes Tres . He wrote about the art of needling for treating diseases including those of the lower urinary tract. He called this technique “acupunctura,” and it was the first Western detailed study on that matter. One of the most commonly used acupuncture points used for gynecological, fertility, digestive, urinary, sexual, and emotional disorders is the SanYinJiao point, or spleen 6. It can be translated as “three yin intersection” because it is the meeting point of the three yin channels of the leg: spleen, liver, and kidney. When electrical current is applied to the acupuncture needle, the technique is called electrical acupuncture. Especially when electroacupuncture is performed with similar stimulation parameters (2–15 Hz, 10–20 mA), it is likely that nerve stimulation is responsible for the clinical effect. Similar effects as with tibial nerve stimulation therefore might be expected on the pelvic organs perhaps as well as on the spleen and on the liver. The fundamental feature of neuromodulation as compared to acupuncture is that nerves are stimulated and not energy pathways or other routes that do not have any anatomical substrate. Nerve stimulation ideally has an efferent motor effect and an afferent sensory effect. Stimulation of posterior tibial nerve results in great toe flexion or fanning of the toes. A 34-gauge stainless steel needle is inserted approximately 3–4 cm, about three fingerbreadths cephalad to the medial malleolus, between the posterior margin of the tibia and soleus muscle. During the initial test stimulation the amplitude is slowly increased until the large toe starts, to curl or toes start to fan. If the large toe does not curl or pain occurs near the insertion site, the stimulation device is switched off and the stimulation again is switched on for the final proper stimulation phase. If the large toe curls or toes start to fan, stimulation is applied at an intensity well tolerated by the patient. In general, patients undergo 12 outpatient treatment sessions, each lasting 30 minutes 1–3 times per week. It is thought that electrical stimulation of the sacral nerve roots modulates the afferent neural reflex pathways between the spinal cord or pons and pelvic organs. As the ascending sensory pathway inputs and guarding reflex pathway are modulated, storage may be facilitated. In the acute phase, brain areas are involved that have to do with sensorimotor learning. These are the areas located in the right postcentral gyrus, the left parietal cortex, the medial prefrontal cortex, and the right insula. Furthermore, there was activation in the ventromedial orbitofrontal cortex and decreased activation in the left medial cerebellum. However, chronic sacral neurostimulation decreased activity in the cerebellum, midbrain, and adjacent midline thalamus and limbic cortical areas, previously implicated in the control of micturition and urinary storage. The recorded P80 and P100 amplitude increase might reflect long-term modifications in synaptic efficiency through the somatosensory pathway induced by repetitive peripheral nerve stimulation. This is in line with the theories about the working mechanism of sacral nerve stimulation. Such a mechanism of action may, in part, explain the clinical effects of this therapy, which seem to be sustained for an extended period of time (weeks to months) following the conclusion of stimulation. Objective success, defined most of the time as more than 50% decrease in incontinence episodes and/or micturition frequency, was found in 47%–56% of patients [8,9]. In these studies, frequency/volume chart data and quality of life scores improved significantly. The breakthrough was that a validated sham arm was developed and used as a comparator. This was the first time that the net effect apart from the placebo effect could be measured. Individuals who noted a moderate or marked improvement were regarded as successfully treated 759 patients. Of this group, 29 patients completed the 36-month protocol and received a median of 1. All quality of life parameters remained markedly improved from baseline through 3 years. These patients also scored worse on disease-specific quality of life questionnaires, although they had no difference in disease severity compared to patients with good mental health. If all successfully treated patients would return every week, this would lead to a jammed outpatient clinic. After implanting the device, the patients could operate the implant by means of an external stimulator. The primary objective was ≥50% reduction in the number of incontinence episodes and/or voids on bladder diary. At 3, 6, and 12 months, respectively, 5, 6, and 4 patients met the primary objective. At 3- and 6-month follow-up, voiding and quality of life parameters had significantly improved. Urinary tract infection, temporary walking difficulties, and spontaneous radiating sensations 760 were reported as adverse events, and there was no local infection, erosion, or dislocation. The seven patients who still had the implant were contacted after nine years and evaluated with an interview, physical examination, ankle x-ray, voiding diaries, and completed questionnaires about adverse events, performance, efficacy, safety, and quality of life with the validated I-QoL. Results showed that six of the seven patients still had sensory and locomotor responses on stimulation at 9-year follow-up. Four patients who had a successful treatment response at one year still used the device. The two electrodes are placed on opposite sides of the tibial nerve just proximal to the medial malleolus. Various articles show different costs since the medical care systems differ between countries. At this moment, there is “circumstantial” evidence existing for its efficacy, based on animal studies, and clinical studies including urodynamic parameters. Subjects for further investigation of areas that already have some clinical efficacy data are children, neurological patients, and patients with fecal incontinence. Stimulation parameters were preset and rather fixed and every time only one needle was inserted. It may well be anticipated that changes in treatment scheme and/or stimulation parameters could lead to a different, possibly even better outcome. It is evident that an accelerated stimulation scheme has the advantage of achieving clinical results faster . Regarding stimulation parameters, it is rather widely agreed that pulse intensity in neuromodulation should be set at a well-tolerated level. Efforts should be undertaken to refine the preimplant testing phase in order to decrease the amount of unnecessarily treated patients. Hopefully, this will eventually lead to the ideal implant: an effective and safe, easily controllable device that is operated by patients themselves in flexible, individualized treatment schemes.