Diet in neurogenic bowel management:A viewpoint on spinal cord injury

The aim of this review is to offer dietary advice for individuals with spinal cord injury(SCI)and neurogenic bowel dysfunction.With this in mind,we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy,autonomic dysreflexia and neurogenic bladder.In addition,SCI is often associated with a sedentary lifestyle,which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation,including cardiovascular and chronic kidney diseases.The Mediterranean diet,along with exercise and dietary supplements,has been suggested as an anti-inflammatory intervention in individuals with SCI.However,individuals with chronic SCI have a daily intake of whole fruit,vegetables and whole grains lower than the recommended dietary allowance for the general population.Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake;therefore,this finding could explain the low consumption of plant foods.Low consumption of fibre induces dysbiosis,which is associated with bothendotoxemia and inflammation.Dysbiosis can be reduced by exercise and diet in individuals with SCI.Therefore,to summarize our viewpoint,we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines.Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI,chronic kidney diseases,chronic pain and irritable bowel syndrome.We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength,flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits.Finally,dietary advice for Paralympic athletes is suggested.

External anal sphincter electromyography in multiple system atrophy:implications for diagnosis,clinical correlations,and novel insights into prognosis

Multiple system atrophy is a sporadic,progressive,adult-onset,neurodegenerative disorder characte rized by autonomic dysfunction symptoms,parkinsonian features,and cerebellar signs in va rious combinations.An early diagnosis of multiple system atrophy is of utmost impo rtance for the proper prevention and management of its potentially fatal complications leading to the poor prognosis of these patients.The current diagnostic criteria incorporate several clinical red flags and magnetic resonance imaging marke rs supporting diagnosis of multiple system atrophy.Nonetheless,especially in the early disease stage,it can be challenging to differentiate multiple system atrophy from mimic disorders,in particular Parkinson’s disease.Electromyography of the external anal sphincter represents a useful neurophysiological tool for diffe rential diagnosis since it can provide indirect evidence of Onuf’s nucleus degeneration,which is a pathological hallmark of multiple system atrophy.However,the diagnostic value of external anal sphincter electromyography has been a matter of debate for three decades due to controve rsial reports in the literature.In this review,after a brief ove rview of the electrophysiological methodology,we first aimed to critically analyze the available knowledge on the diagnostic role of external anal sphincter electromyography.We discussed the conflicting evidence on the clinical correlations of neurogenic abnormalities found at external anal sphincter electro myography.Finally,we repo rted recent prognostic findings of a novel classification of electromyography patterns of the external anal sphincter that could pave the way toward the implementation of this neurophysiological technique for survival prediction in patients with multiple system atrophy.

Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders

AIM To investigate compliance with transanal irrigation(TAI) one year after a training session and to identify predictive factors for compliance.METHODS The compliance of one hundred eight patients [87 women and 21 men; median age 55 years(range 18-83)] suffering from constipation or fecal incontinence(FI) was retrospectively assessed. The patients were trained in TAI over a four-year period at a single institution. They were classified as adopters if they continued using TAI for at least one year after beginning the treatment or as non-adopters if they stopped. Predictive factors of compliance with TAI were based on pretreatment assessments and trainingprogress. The outcomes of the entire cohort of patients who had been recruited for the TAI treatment were expressed in terms of intention-to-treat.RESULTS Forty-six of the 108(43%) trained patients continued to use TAI one year after their training session. The patients with FI had the best results, with 54.5% remaining compliant with TAI. Only one-third of the patients who complained of slow transit constipation or obstructed defecation syndrome continued TAI. There was an overall discontinuation rate of 57%. The most common reason for discontinuing TAI was the lack of efficacy(41%). However, 36% of the patients who discontinued TAI gave reasons independent of the efficacy of the treatment such as technical problems(catheter expulsion, rectal balloon bursting, instilled water leakage or retention, pain during irrigation, anal bleeding, anal fissure) while 23% said that there were too many constraints. Of the patients who reported discontinuing TAI, the only predictive factor was the progress of the training(OR = 4.9, 1.3-18.9, P = 0.02).CONCLUSION The progress of the training session was the only factor that predicted patient compliance with TAI.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries(SPS)for rectal cancer.The bowel dysfunction usually manifests in the form of low anterior resection syndrome(LARS),which has a negative impact on the patients'quality of life.This study reviewed the LARS after SPS,its mechanism,risk factors,diagnosis,prevention,and treatment based on previously published studies.Adequate history taking,physical examination of the patients,using validated questionnaires and other diagnostic tools are important for assessment of LARS severity.Treatment of LARS should be tailored to each patient.Multimodal therapy is usually needed for patients with major LARS with acceptable results.The treatment includes conservative management in the form of medical,pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation.If this treatment failed,fecal diversion may be needed.In conclusion,Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS.Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.