Outcomes and efficacy of magnetic resonance imaging-compatible sacral nerve stimulator for management of fecal incontinence: A multi-institutional study

BACKGROUND Fecal incontinence(FI)is an involuntary passage of fecal matter which can have a significant impact on a patient’s quality of life.Many modalities of treatment exist for FI.Sacral nerve stimulation is a well-established treatment for FI.Given the increased need of magnetic resonance imaging(MRI)for diagnostics,the In-terStim which was previously used in sacral nerve stimulation was limited by MRI incompatibility.Medtronic MRI-compatible InterStim was approved by the United States Food and Drug Administration in August 2020 and has been widely used.AIM To evaluate the efficacy,outcomes and complications of the MRI-compatible InterStim.METHODS Data of patients who underwent MRI-compatible Medtronic InterStim placement at UPMC Williamsport,University of Minnesota,Advocate Lutheran General Hospital,and University of Wisconsin-Madison was pooled and analyzed.Patient demographics,clinical features,surgical techniques,complications,and outcomes were analyzed.Strengthening the Reporting of Observational studies in Epidemiology(STROBE)cross-sectional reporting guidelines were used.RESULTS Seventy-three patients had the InterStim implanted.The mean age was 63.29±12.2 years.Fifty-seven(78.1%)patients were females and forty-two(57.5%)patients had diabetes.In addition to incontinence,overlapping symptoms included diarrhea(23.3%),fecal urgency(58.9%),and urinary incontinence(28.8%).Fifteen(20.5%)patients underwent Peripheral Nerve Evaluation before proceeding to definite implant placement.Thirty-two(43.8%)patients underwent rechargeable InterStim placement.Three(4.1%)patients needed removal of the implant.Migration of the external lead connection was observed in 7(9.6%)patients after the stage I procedure.The explanation for one patient was due to infection.Seven(9.6%)patients had other complications like nerve pain,hematoma,infection,lead fracture,and bleeding.The mean follow-up was 6.62±3.5 mo.Sixty-eight(93.2%)patients reported significant improvement of symptoms on follow-up evaluation.CONCLUSION This study shows promising results with significant symptom improvement,good efficacy and good patient outcomes with low complication rates while using MRI compatible InterStim for FI.Further long-term follow-up and future studies with a larger patient population is recommended.

Prolonged electrical stimulation causes no damage to sacral nerve roots in rabbits

Previous studies have shown that, anode block electrical stimulation of the sacral nerve root can produce physiological urination and reconstruct urinary bladder function in rabbits. However, whether long-term anode block electrical stimulation causes damage to the sacral nerve root re- mains unclear, and needs further investigation. In this study, a complete spinal cord injury model was established in New Zealand white rabbits through T9_10 segment transection. Rabbits were given continuous electrical stimulation for a short period and then chronic stimulation for a longer period. Results showed that compared with normal rabbits, the structure of nerve cells in the anterior sacral nerve roots was unchanged in spinal cord injury rabbits after electrical stimu- lation. There was no significant difference in the expression of apoptosis-related proteins such as Bax, Caspase-3, and Bcl-2. Experimental findings indicate that neurons in the rabbit sacral nerve roots tolerate electrical stimulation, even after long-term anode block electrical stimulation.

Adverse events of sacral neuromodulation for fecal incontinence reported to the federal drug administration

AIM:To investigate the nature and severity of AE related to sacral neurostimulation(SNS).METHODS:Based on Pubmed and Embase searches,we identified published trials and case series of SNS for fecal incontinence(FI)and extracted data on adverse events,requiring an active intervention.Those problems were operationally defined as infection,device removal explant or need for lead and/or generator replacement.In addition,we analyzed the Manufacturer and User Device Experience registry of the Federal Drug Administration for the months of August-October of2015.Events were included if the report specifically mentioned gastrointestinal(GI),bowel and FI as indication and if the narrative did not focus on bladder symptoms.The classification,reporter,the date of the recorded complaint,time between initial implant and report,the type of AE,steps taken and outcome were extracted from the report.In cases of device removal or replacement,we looked for confirmatory comments by healthcare providers or the manufacturer.RESULTS:Published studies reported adverse events and reoperation rates for 1954 patients,followed for 27(1-117)mo.Reoperation rates were 18.6%(14.2-23.9)with device explants accounting for 10.0%(7.8-12.7)of secondary surgeries;rates of device replacement or explant or pocket site and electrode revisions increased with longer follow up.During the period examined,the FDA received 1684 reports of AE related to SNS with FI or GI listed as indication.A total of 652 reports met the inclusion criteria,with 52.7%specifically listing FI.Lack or loss of benefit(48.9%),pain or dysesthesia(27.8%)and complication at the generator implantation site(8.7%)were most commonly listed.Complaints led to secondary surgeries in 29.7%of the AE.Reoperations were performed to explant(38.2%)or replace(46.5%)the device or a lead,or revise the generator pocket(14.6%).Conservative management changes mostly involved changes in stimulation parameters(44.5%),which successfully addressed concerns in 35.2%of cases that included information about treatment results.CONCLUSION:With reoperation rates around 20%,physicians need to fully disclose the high likelihood ofcomplications and secondary interventions and exhaust non-invasive treatments,including transcutaneous stimulation paradigms.

Sphincteroplasty for fecal incontinence in the era of sacral nerve modulation

The role of sphincteroplasty in the treatment of patients with fecal incontinence due to anal sphincter defects has been questioned because the success rate declines in the long-term.A new emerging treatment for fecal incontinence,sacral nerve stimulation,has been shown to be effective in these patients.However,the success rate of sphincteroplasty may depend of several patient-related and surgical-related factors and the outcome from sphincteroplasty has been evaluated differently(with qualitative data) from that after sacral nerve stimulation(quantitative data using scoring systems and quality of life).Furthermore,the data available so far on the longterm success rate after sacral nerve modulation do not differ substantially from those after sphincteroplasty.The actual data do not support the replacement of sphincteroplasty with sacral nerve stimulation in patients with fecal incontinence secondary to sphincter defects.

Combined Sacral Nerve Roots Stimulation and Low Thoracic Spinal Cord Stimulation for the Treatment of Chronic Pelvic Pain

Some pelvic pain syndromes are very resistant to medical treatment. Several studies have demonstrated that sacral neuromodulation, which has been successfully used for the treatment of bladder dysfunction, incontinence, urinary retention and urinary frequency [1]-[3], can be successfully used for the treatment of chronic pelvic pain [4]-[7]. Several studies have also demonstrated significant involvement of dorsal column pathways in the transmission of visceral pelvic pain [8] and the successful use of spinal cord stimulation for the treatment of chronic pelvic pain [9]. We report three cases of severe chronic pelvic pain that failed conservative treatment modalities. Placement of a combined sacral nerve roots stimulator and a low thoracic spinal cord stimulator resulted in a significant pain relief and improvement in daily life activities. We believe that this combination may help patients suffering from chronic pelvic pain resistant to medical management.

Electrical neuromodulation therapy for inflammatory bowel disease

Inflammatory bowel disease(IBD)is an inflammatory disease of the gastrointestinal(GI)tract.It has financial and quality of life impact on patients.Although there has been a significant advancement in treatments,a considerable number of patients do not respond to it or have severe side effects.Therapeutic approaches such as electrical neuromodulation are being investigated to provide alternate options.Although bioelectric neuromodulation technology has evolved significantly in the last decade,sacral nerve stimulation(SNS)for fecal incontinence remains the only neuromodulation protocol commonly utilized use for GI disease.For IBD treatment,several electrical neuromodulation techniques have been studied,such as vagus NS,SNS,and tibial NS.Several animal and clinical experiments were conducted to study the effectiveness,with encouraging results.The precise underlying mechanisms of action for electrical neuromodulation are unclear,but this modality appears to be promising.Randomized control trials are required to investigate the efficacy of intrinsic processes.In this review,we will discuss the electrical modulation therapy for the IBD and the data pertaining to it.

Electrical stimulation with polypyrrole-coated polycaprolactone/silk fibroin scaffold promotes sacral nerve regeneration by modulating macrophage polarisation

Peripheral nerve injury poses a great threat to neurosurgery and limits the regenerative potential of sacral nerves in the neurogenic bladder.It remains unknown whether electrical stimulation can facilitate sacral nerve regeneration in addition to modulate bladder function.The objective of this study was to utilise electrical stimulation in sacra nerve crush injury with newly constructed electroconductive scaffold and explore the role of macrophages in electrical stimulation with crushed nerves.As a result,we generated a polypyrrole-coated polycaprolactone/silk fibroin scaffold through which we applied electrical stimulation.The electrical stimulation boosted nerve regeneration and polarised the macrophages towards the M2 phenotype.An in vitro test using bone marrow derived macrophages revealed that the pro-regenerative polarisation of M2 were significantly enhanced by electrical stimulation.Bioinformatics analysis showed that the expression of signal transducer and activator of transcriptions(STATs)was differentially regulated in a way that promoted M2-related genes expression.Our work indicated the feasibility of electricals stimulation used for sacral nerve regeneration and provided a firm demonstration of a pivotal role which macrophages played in electrical stimulation.

Current management of fecal incontinence:Choosing amongst treatment options to optimize outcomes

The severity of fecal incontinence widely varies and can have dramatic devastating impacts on a person’s life.Fecal incontinence is common,though it is often underreported by patients.In addition to standard treatment options,new treatments have been developed during the past decade to attempt to effectively treat fecal incontinence with minimal morbidity.Non-operative treatments include dietary modifications,medications,and biofeedback therapy.Currently used surgical treatments include repair(sphincteroplasty),stimulation(sacral nerve stimulation or posterior tibial nerve stimulation),replacement(artificial bowel sphincter or muscle transposition)and diversion(stoma formation).Newer augmentation treatments such as radiofrequency energy delivery and injectable materials,are minimally invasive tools that may be good options before proceeding to surgery in some patients with mild fecal incontinence.In general,more invasive surgical treatments are now reserved for moderate to severe fecal incontinence.Functional and quality of life related outcomes,as well as potential complications of the treatment must be considered and the treatment of fecal incontinence must be individualized to the patient.General indications,techniques,and outcomes profiles for the various treatments of fecal incontinence are discussed in detail.Choosing the most effective treatment for the individual patient is essential to achieve optimal outcomes in the treatment of fecal incontinence.

Non-invasive transcutaneous electrical stimulation in the treatment of overactive bladder

We reviewed the literature on transcutaneous electrical nerve stimulation(TENS)used as a therapy for overactive bladder(OAB)symptoms,with a particular focus on:stimulation site,stimuli parameters,neural structures thought to be targeted,and the clinical and urodynamic outcomes achieved.The majority of studies used sacral or tibial nerve stimulation.The literature suggests that,whilst TENS therapy may have neuromodulation effects,patient are unlikely to benefit to a significant extent from a single application of TENS and indeed clear benefits from acute studies have not been reported.In long-term studies there were differences in the descriptions of stimulation intensity,strategy of the therapy,and positioning of the electrodes,as well as in the various symptoms and pathology of the patients.Additionally,most studies were uncontrolled and hence did not evaluate the placebo effect.Little is known about the underlying mechanism by which these therapies work and therefore exactly which structures need to be stimulated,and with what parameters.There is promising evidence for the efficacy of a transcutaneous stimulation approach,but adequate standardisation of stimulation criteria and outcome measures will be necessary to define the best way to administer this therapy and document its efficacy.

The Role of Acupuncture Treatment in Obstructed Defecation Syndrome

Background:Obstructed defecation syndrome(ODS)is a group of symptoms that are mainly caused by pelvic floor dysfunction concerning bowel symptoms.It is challenging in clinical practice.Acupuncture has advantages in the treatment of complex symptoms because of its multi-target and bi-directional regulation of the human body.Since 2500 years ago,acupuncture has been applied empirically to the treatment of constipation.Does acupuncture have any effect on ODS?Objectives:By showing the clinical thoughts,methods,and achievements of acupuncture series in ODS in recent ten years by the author’s team,and two scientific papers published in English on acupuncture treatment of chronic intractable constipation and stress urinary incontinence,it is proved that the core scheme of acupuncture treatment of defecation disorder syndrome(ODS)is flexible.In order to raise awareness of the therapeutic effect of acupuncture in ODS,it can be integrated into existing practice to get opportunities for multidisciplinary cooperation and further research and development.Materials and Methods:By summarizing the diagnosis and treatment of ODS,the first-line selection of pelvic floor rehabilitation and the minimally invasive sacral neuromodulation were reviewed,and it was pointed out that there was a gap between the high demand of patients and the expectation of cost-effectiveness.Then,on the basis of modern eastern and western medical achievements,the holistic concept was introduced into the treatment of pelvic floor dysfunction,and an acupuncture scheme suitable for ODS was proposed.Results:Acupuncture is based on the idea of improving the patients’central nervous system,autonomic nervous system and intestinal nervous system,and is effective in treating ODS.The acupoints were set two groups when patient in supine position,which includes ST 25(Tianshu),SP 15(Daheng),SP 14(Fujie),CV 6(Qihai),CV 4(Guanyuan),ST 36(Zusanli),ST 37(Shangjuxu);When patient is in prone position,it includes BL 20(Pishu),BL 23(Shenshu),BL 25(Dachangshu),BL 33(Zhongliao),BL 34(Xialiao),and GV 20(Baihui).The key was the technique of deep needling of the ST 25(Tianshu)and deep needling of the BL 33(Zhongliao)&BL 34(Xialiao).It needs 2-15 Hz sparse-dense wave electrical stimulation,30 minutes each time,a total of 20 times,which was a scheme that could achieve satisfactory short-term and long-term effects.Conclusion:At present,clinical and basic experimental studies have proved that acupuncture plays a role in treating ODS in a multi-target way.This is a very promising research direction of pelvic floor integrated medicine.In the future,further study on optimizing the protocol and meeting the patient’s gap individually and cost-effectively.

神经刺激仪引导下腰丛联合骶丛神经阻滞麻醉在股骨颈骨折患者中的应用

目的:探讨在股骨颈骨折患者中应用神经刺激仪引导下腰丛联合骶丛神经阻滞麻醉的效果。方法:选取2020年1月—2023年6月桂林市中医医院收治的98例股骨颈骨折患者作为研究对象,按照随机数表法将其分为对照组和研究组,各49例。对照组采用传统的腰硬联合麻醉,研究组采用神经刺激仪引导下腰丛联合骶丛神经阻滞麻醉。比较两组麻醉效果、平均动脉压(MAP)、心率(HR)、皮质醇(Cor)和儿茶氨酚(CA)及不良反应。结果:两组麻醉效果比较,差异无统计学意义(P>0.05)。研究组麻醉后15 min(T_(2))、麻醉后30 min(T_(3))时MAP高于对照组,差异有统计学意义(P<0.05);研究组麻醉后5 min(T_(1))、T_(2)、T_(3)、手术结束后(T_(4))时HR高于对照组,差异有统计学意义(P<0.05)。研究组术中(Tb)时CA、Cor低于对照组,差异有统计学意义(P<0.05)。两组不良反应发生率比较,差异无统计学意义(P>0.05)。结论:股骨颈骨折患者应用神经刺激仪引导下腰丛联合骶丛神经阻滞麻醉能稳定血流动力学,缓解应激反应,具有良好的麻醉效果和较高的安全性。

骶神经磁刺激对脊髓损伤后逼尿肌无力型膀胱的疗效分析

目的:探讨骶神经磁刺激对脊髓损伤后逼尿肌无力型膀胱的影响。方法:采取随机分组的方法将36例脊髓损伤合并逼尿肌无力型膀胱患者分为试验组与对照组。两组患者均接受常规康复治疗,试验组对S3神经根进行重复功能性磁刺激(repetitive functional magnetic stimulation,r FMS)治疗。于治疗前、治疗4周后分别观察2组患者的简易膀胱容量测定、膀胱超声及焦虑自评量表等指标。结果:2组患者最大自排尿量、平均自排尿量、残余尿量、膀胱初感觉容量及焦虑自评评分与治疗前相比均有所改善,治疗后试验组的最大自排尿量、平均自排尿量均显著优于对照组,具有显著性差异(P<0.05)。结论:重复功能磁刺激作用于骶神经根对治疗脊髓损伤后逼尿肌无力型患者疗效明显优于常规治疗,疗法为临床上治疗逼尿肌无力型神经源性膀胱提供新思路。

神经电刺激治疗功能性肛门直肠及盆腔疼痛研究进展

从神经电刺激入手,阐述电针、骶神经刺激、胫神经刺激等疗法对功能性肛门直肠及盆腔疼痛的疗效和作用机制,认为神经电刺激具有安全、微创、快速镇痛等特点,对于功能性肛门直肠及盆腔疼痛具有较好的疗效,是一种可行的治疗策略,未来还需更多大样本、多中心的研究进一步验证其疗效。

电刺激治疗脊髓损伤后神经源性膀胱的研究新进展

神经源性膀胱(neurogenic bladder,NB)是指由于神经系统病变引发的下尿路功能障碍(lower urinary tract dysfunction,LUTD),患者表现为一系列下尿路症状(lower urinary tract syndrome,LUTS),NB也是脊髓损伤(spinal cord injury,SCI)后常见的严重并发症,给患者生活质量和康复进程带来显著影响,甚至可导致患者死亡。因此,SCI后NB的研究也是重点与难点。当前,对于SCI后NB的治疗并没有明确有效的治疗方法,寻找安全有效的治疗方法迫在眉睫。SCI后由于神经反射通路受损,导致NB的发生,而长期反复的足疗程电刺激,可以重塑神经环路,这一观点与SCI后NB的发生机制不谋而合。电刺激治疗疾病作为一种非侵入性治疗手段,近年来显现出一定的治疗优势,是一种极具前景的治疗途径。学习近年来相关电刺激文献后对不同类型电刺激治疗SCI后NB的机制、电刺激部位、治疗效果以及安全性进行综述,以期为电刺激治疗SCI后NB提供参考。

补中益气丸联合骶神经S_(2)~S_(4)磁刺激治疗间质性膀胱炎的效果

目的探究补中益气丸联合骶神经S_(2)-S_(4)磁刺激治疗间质性膀胱炎(IC)的效果。方法选取2021年1月至2022年11月接诊的126例IC患者为研究对象,按照随机数字表法将其分为对照组和试验组,每组63例。两组均予以骶神经S_(2)-S_(4)磁刺激治疗,对照组在此基础上口服安慰剂,试验组在此基础上口服补中益气丸。比较两组的治疗效果。结果试验组的疼痛治愈率及缓解率高于对照组,差异具有统计学意义(P<0.05)。试验组的尿频治愈率高于对照组,差异具有统计学意义(P<0.05)。试验组的夜尿次数多治愈率高于对照组,差异具有统计学意义(P<0.05)。结论补中益气丸联合骶神经S_(2)-S_(4)磁刺激治疗IC的效果显著,可减轻患者的盆腔疼痛程度,改善尿频、夜尿增多等症状,值得临床进一步推广和应用。

Electroacupuncture in liver regeneration:a Chinese traditional medicine approach to enhancing liver regeneration

We read with great interest the paper by Yang et al.,published in Advanced Science(1),which presents an intriguing exploration into the use of electroacupuncture(EA)to enhance liver regeneration.This study primarily investigates the roles of the vagus nerve and hepatic macrophages in facilitating liver regeneration,focusing on the brain-liver axis and the underlying mechanisms.

骶神经磁刺激联合生物反馈在以产后性交痛为主的FSD患者中的应用效果

目的:探讨骶神经磁刺激联合生物反馈在以产后性交痛为主的女性性功能障碍(FSD)患者中的应用效果。方法:选取2023年1—12月毕节市七星关区妇幼保健院收治的200例以产后性交痛为主的FSD患者作为研究对象,根据康复治疗方案的不同将研究对象分为观察组和对照组,各100例。对照组采用常规盆底功能康复治疗,观察组采用骶神经磁刺激联合生物反馈治疗,比较两组盆底肌力评分、性功能评分、盆底肌电值及雌激素水平。结果:观察组治疗15 d、30 d盆底肌力评分高于对照组,差异有统计学意义(P<0.05);观察组治疗30 d女性性功能调查量表(FSFI)评分高于对照组,差异有统计学意义(P<0.05);观察组治疗后盆底肌电值正常比例及雌二醇、孕酮和促卵泡激素水平高于对照组,差异有统计学意义(P<0.05)。结论:骶神经磁刺激联合生物反馈治疗可提高以产后性交痛为主要表现的FSD患者的盆底肌力评分、性功能评分、盆底肌电值正常比例及雌激素水平。

居家训练联合骶神经磁刺激及盆底肌康复训练对慢性盆腔痛患者长期疗效观察

目的:探究居家训练联合骶神经磁刺激及盆底肌康复训练对慢性盆腔痛疗效。方法:选取本院2022年6月-2023年6月收治的慢性盆腔痛100例患者分为两组(随机数字表法)各50例,对照组中途脱落10例,共计纳入40例;两组均采用骶神经磁刺激及盆底肌康复训练干预,观察组出院后居家训练,两组均随访6个月。比较两组治疗效果、盆底肌肌力、盆底肌压痛、盆底表面肌电Glazer评估情况以及不良反应。结果:观察组治疗后临床总体印象改善量表(CGI-I)评分(3.05±0.69分)高于对照组(2.12±0.57分),两组治疗后盆底肌肌力均提升,观察组Laycock改良牛津肌力分级法(MOS)分级优于对照组,两组治疗后视觉模拟评分(VAS)评分均下降且观察组(2.84±1.06分)低于对照组(3.65±1.44分);两组治疗后快速收缩放松时间、前静息平均肌电值与后静息平均肌电值均减少,且观察组(3.24±1.06 s、4.83±1.45μV、4.15±0.81μV)低于对照组(4.01±1.12 s、5.66±1.61μV、4.81±0.95μV)(均P<0.05);两组治疗期间均未出现明显不良反应;随访期间复发率观察组(1例,2.0%)与对照组(4例,10.0%)无差异(Fisher精确概率=0.167)。结论:慢性盆腔痛患者采用居家训练联合骶神经磁刺激及盆底肌康复训练治疗效果良好,患者盆底肌肌力与盆底表面肌电情况得到显著改善,疼痛得到缓解且安全性较高。

坦索罗辛联合骶神经根磁刺激治疗Ⅲ型前列腺炎伴性功能障碍患者临床研究

目的探讨坦索罗辛联合骶神经根磁刺激对Ⅲ型前列腺炎伴性功能的治疗效果。方法选取2021年1月~2023年1月本院收治的100例Ⅲ型CP患者作为研究对象。据患者初次诊断的顺序编号,按奇偶数法分为观察组与对照组,各50例。其中对照组使用坦索罗辛治疗,观察组使用坦索罗辛联合骶神经根磁刺激治疗。观察两组治疗前后疗效、慢性前列腺炎症状指数(NIH-CPSI)和国际勃起功能指数-5(IIEF-5)评分及血清白介素2、8(IL-2、IL-8)和肿瘤坏死因子(TNF-α)水平。结果观察组总有效率明显高于对照组(P<0.05)。治疗后,两组NIH-CPSI评分较治疗前显著降低,IIEF-5评分则较治疗前显著升高(P<0.05);且观察组NIH-CPSI评分显著低于对照组,IIEF-5评分则明显高于对照组(P<0.05)。治疗后,两组前各项炎症因子均显著降低(P<0.05),且观察组前各项炎症因子显著低于对照组(P<0.05)。结论坦索罗辛联合骶神经根磁刺激可有效改善前列腺炎症状和勃起功能,还能降低血清炎症因子水平。

骶神经磁刺激联合盆底肌筋膜手法治疗对慢性盆腔痛患者的效果及对Glazer评估指标的影响

目的探讨骶神经磁刺激联合盆底肌筋膜手法治疗慢性盆腔痛(CPP)的效果及对Glazer评估指标的影响。方法选择徐州市康复医院2022年1月—2023年12月收治的90例CPP患者为研究对象,按照随机数字表法将其分为对照组和观察组,每组45例。对照组采用盆底肌筋膜手法治疗,观察组在对照组基础上采用骶神经磁刺激治疗,两组均持续治疗4周。对比两组患者的临床疗效、Glazer评估指标及疼痛程度。结果观察组的治疗总有效率为93.33%,高于对照组的75.56%,差异有统计学意义(P<0.05)。治疗后,观察组前静息平均肌电值、后静息平均肌电值分别为(4.91±0.82)uV、(4.11±0.47)uV,均低于对照组,快肌最大肌电值、慢肌平均肌电值分别为(36.82±6.52)uV、(33.39±5.92)uV,均高于对照组,快速收缩放松时间为(3.11±0.31)s,短于对照组,组间差异有统计学意义(P<0.05);观察组的疼痛视觉模拟评分为(1.41±0.45)分,低于对照组的(3.03±0.82)分,差异有统计学意义(P<0.05)。结论骶神经磁刺激联合盆底肌筋膜手法治疗CPP的效果显著,能有效减轻患者疼痛,改善Glazer评估指标。