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Background and Purpose Pure autonomic failure (PAF) presents primarily as cardiovascular autonomic failure and may phenoconvert to other neurodegenerative disorders. However, the involvement of other autonomic functions has been poorly evaluated. This study aims to characterize genitourinary and bowel dysfunction and explore their relationship with cardiovascular autonomic dysfunction. Methods Pure autonomic failure patients underwent cardiovascular autonomic testing and an assessment of pelvic autonomic dysfunction using urinary, sexual symptoms questionnaires and a bladder diary. Demographic, clinical features and related medical comorbidities were assessed. Results Twenty‐five patients (10 males) with PAF were included (mean age 71 ± 8 years; disease duration 13 ± 8 years). 96% (24/25) reported lower urinary tract symptoms, of which overactive bladder symptoms were most commonly reported (n = 23; 92%; median overactive subscore 8, interquartile range [IQR] 3–11), followed by voiding difficulties (n = 19; 76%; median low stream subscore 2, IQR 1–3) using the Urinary Symptom Profile; however, only four (16%) required clean intermittent self‐catheterization. Sexual dysfunction was common (n = 21; 84%) using the Arizona Sexual Experience Scale. Mild faecal incontinence and constipation were reported. 86% (19/22) had nocturnal polyuria (NP) and the median NP index was 47% (IQR 38%–51%; normal range <33%). 77% (10/13) had voiding dysfunction and 31% (4/13) had post‐void residual urine >100 mL. There were no significant correlations between the need for catheterization and the degree of NP with age, disease duration and cardiovascular autonomic parameters (p > 0.05). Conclusions Nocturnal polyuria, genitourinary and bowel symptoms are commonly seen in PAF. The pathophysiology of NP in PAF is most likely multifactorial and may occur independent of cardiovascular autonomic failure.

Purpose To report the etiology, presenting symptoms and outcomes of the different treatments performed in female patients with recurrent urethral stricture. Materials and methods Twenty-six patients with refractory LUTS were diagnosed with a urethral stricture. The symptoms, the treatment performed and the outcomes were prospectively recorded. Sixteen patients were treated with a urethroplasty using a buccal mucosal graft (BMG) in 14 cases (54 %) and a vaginal flap in 2 (8 %). Urethral dilatation, optical urethrotomy and meatoplasty were performed in 8 (31 %), 1 (3.8 %) and 1 (3.8 %) patients, respectively. Results Strictures were idiopathic in 11 patients (42 %). Previous urethral instrumentation and traumatic vaginal delivery were the commonest causes of urethral stricture (42 and 15 %, respectively). The most frequent symptoms were reduced flow (93 %), detrusor overactivity (50 %) and UTIs (42 %). The stricture was cured in 93 % of patients treated with a BMG urethroplasty and in all the patients in which a vaginal flap urethroplasty was performed. In the same group, the improvement in urethral pain was observed in the 67 and the 88 % of patients were cured from recurrent UTIs. All the patients treated with urethral dilatation needed further dilatations; hence, the cure of the stricture was achieved in none of them. Improvement in urethral pain, UTIs and detrusor activity was not recorded in the latter group. Conclusion Urethroplasty in its various forms has demonstrated in the present series the highest cure rate for the treatment of recurrent urethral stricture.

ObjectivesSacral Tarlov cysts (TC) are frequent incidental findings on spinal MRI. Controversy remains regarding their ability to cause nerve root compression. Pelvic neurophysiological and urodynamics testing provides information about sacral nerve root involvement.DesignCase seriesSubjectsPatients with MRI evidence of sacral (S1, 2 or 3) TC seen in the Uro-neurology Department between 2011 and 2018.MethodsClinical, neurophysiological and urodynamics data were reviewed.Results13 patients (9 females, mean age54/SD13.1) were included. Symptoms were urgency/incontinence (n=8), hesitancy/urinary retention (n=7), bowel complaints (n=4), sexual complaints (n=3), back pain (n=5), genital/pelvic pain (n=6), genital numbness (n=5), impaired sensation of bladder fullness (n=2), lower limb (LL) pain/hypoesthesia (n=6), LL weakness (n=2). The following neurophysiological abnormalities were seen: anal sphincter EMG (n=10) evidence for reinnervation (n=8), pudendal sensory evoked potentials (SEPs) (n=6) absent response (n=1), S2 and S3 dermatomal SEPs (n=6) absent response (n=2), sympathetic skin response (n=6) absent response (n=3). Findings in cystometry (n=5) were: detrusor underactivity (n=2), detrusor after-contraction (n=1), equivocal obstructed voiding (n=1) and reduced bladder compliance (n=1).ConclusionsAbnormal results in urodynamics and pelvic neurophysiology suggest involvement of the somatic and autonomic sacral innervation. Further studies are required to explore any association between structural changes on MRI and functional changes in urodynamics and neurophysiology.

PurposeTo establish the correlation between flow rate curve shape and video-urodynamic findings in women with lower urinary tract symptoms (LUTS). MethodsA retrospective review of consecutive women with LUTS who performed a free flow study immediately before undergoing video-urodynamic investigations over a 28-month period. Flow rate curve shape and video-urodynamic parameters were analysed. Free flow curves were defined into five categories: bell-shaped, prolonged, fluctuating, intermittent or plateau. Women who voided less than 150 ml on the free flow study were excluded from the analysis. ResultsA total of 250 women with LUTS, with a mean age 48 years (range 18–83), were included. Bell-shaped tracings excluded obstruction in 89%. Prolonged flow rate curves diagnosed obstruction in 62% and detrusor underactivity in 8%. Fluctuating and intermittent flow rate curves were associated with urodynamic obstruction in 37 and 39%, respectively, and detrusor underactivity in 25 and 29%, respectively. A plateau flow rate curve was indicative of urodynamic obstruction in all three cases observed. ConclusionFlow rate curve patterns can be suggestive of urodynamic diagnoses. Women without a prolonged void and bell-shaped traces had normal voiding urodynamics in 76% of cases, and the majority could be managed without invasive investigations. Patients with fluctuating and intermittent flow rate curves demonstrate a spectrum of urodynamic diagnoses with a third of cases having obstruction and a third of cases having detrusor underactivity. Plateau flow rate curve patterns are associated with urethral obstruction.

IntroductionPercutaneous tibial nerve stimulation (PTNS) is effective for managing multiple sclerosis (MS)-related overactive bladder (OAB) symptoms. However the need for weekly clinic visits restricts its use. The purpose of this study was to evaluate safety and efficacy of a novel, self-applying device for managing OAB symptoms.Study design, materials and methods48 patients reporting OAB (MS n=24, idiopathic n=24), were randomized (1:1) to either daily or weekly treatments for 12 weeks with geko™, a novel device stimulating the tibial nerve transcutaneously. Efficacy was assessed using validated questionnaires (ICIQ-OAB, ICIQLUTS-QoL) and bladder diaries filled at weeks 4, 8, and 12. Urinary neurotrophins (Nerve growth factor (NGF) and Brain derived neurotrophic factor) were measured.Results34 patients (MS n=19) completed the study. 18 patients responded to treatment (53%); 72% of responders belonged to the MS cohort. Multilevel regression analysis suggested significant improvements in questionnaire scores (ICIQ-OAB –10.2 (–13.5 to –6.9; p=0.001), ICIQLUTS-QOL –40.8 (–57.4 to –24.3; p=0.000)), without differences between weekly and daily-treated arms. No significant adverse effects were reported and patients rated the treatment as easy to use and comfortable. NGF levels at baseline were significantly greater in non-responders (p=0.05).Concluding messageIn this pilot study, a patch device suitable for self-application at home appears to be an effective, safe and convenient alternative for managing MS-related OAB symptoms.

In this paper, a direct method is presented to analyze the stability of fractional order systems with single and multiple commensurate time delays, against delay uncertainties.. It is shown that this method analytically reveals all possible stability windows exclusively in the parametric space of the time delay. Using the approach presented in this study, first, without using any approximation or substitution, the transcendental characteristic equation is converted to an algebraic one with some specific crossing points. The resulting algebraic equation also enables us to easily determine the delay dependency of the system stability and the sensitivities of crossing roots with respect to time delay. Then, an expression in terms of system parameters and imaginary root of the characteristic equation is derived for computing the delay margin .The number of unstable roots in each interval is calculated with the definition of root tendency on the boundary of each interval. Finally, the concept of stability is expressed as a function of delay. four illustrative examples are presented to confirm the proposed method results.

In this study, we calculate accurate absolute locations for nearly 3,000 shallow earthquakes (≤20 km depth) that occurred from 1996 to 2010 in the Central Alborz region of northern Iran using a non-linear probabilistic relocation algorithm on a local scale. We aim to produce a consistent dataset with a realistic assessment of location errors using probabilistic hypocenter probability density functions. Our results indicate significant improvement in hypocenter locations and far less scattering than in the routine earthquake catalog. According to our results, 816 earthquakes have horizontal uncertainties in the 0.5–3.0 km range, and 981 earthquakes are relocated with focal-depth errors less than 3.0 km, even with a suboptimal network geometry. Earthquake relocated are tightly clustered in the eastern Tehran region and are mainly associated with active faults in the study area (the Mosha and Garmsar faults). Strong historical earthquakes have occurred along the Mosha and Garmsar faults, and the relocated earthquakes along these faults show clear north-dipping structures and align along east–west lineations, consistent with the predominant trend of faults within the study region. After event relocation, all seismicity lies in the upper 20 km of the crust, and no deep seismicity (>20 km depth) has been observed. In many circumstances, the seismicity at depth does not correlate with surface faulting, suggesting that the faulting at depth does not directly offset overlying sediments.

Background Optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates mobilization and theoretically reduces associated complications. Methods We identified consecutive patients without neurologic injury requiring stabilization surgery for a spinal fracture at an academic tertiary-care hospital over a 12-year period. Incidences of postoperative complications were prospectively evaluated. We analyzed results based on the time elapsed before the final surgical stabilization procedure. Multivariate analyses were performed to explore the effects of potential confounders. Results A total of 83 patients (60 men, 23 women; mean age 39.4 yr) met the eligibility criteria and were enrolled. The mean Injury Severity Score (ISS) was 27.1 (range 12.0–57.0); 35% of patients had a cervical fracture and 65% had a thoracolumbar fracture. No statistically significant associations were uncovered between time to surgical stabilization and age, ISS or comorbidities. Comparing patients stabilized after 24 hours with those stabilized within 24 hours, there was an almost 8-fold greater risk of a complication related to prolonged recumbency ( p = 0.007). We observed similar effects for other types of complications. Delays of more than 72 hours had a negative effect on complication rates; these effects remained significant after multivariate adjustments for age, comorbidity and ISS. Conclusion This study demonstrates a strong relation between timing of surgical stabilization of spinal fractures in multitrauma patients without neurologic injuries and complications. Further studies with larger samples may allow for better adjustment of potentially confounding factors and identify subgroups in which this effect is most pronounced.

IntroductionThere are estimated to be 3.4 million patients in the UK living after a diagnosis of cancer. We know very little about their quality of life or healthcare usage. Patient-reported outcome measures (PROMs) are tools which help to translate a patient’s quality of life into measurable categories, but how to do this at scale remains underexplored. The study employs a randomised design to assess different engagement strategies for optimising participation, data linkage and questionnaire completion in Northwest London and then nationally, with appropriate research approvals.Methods and analysisWe have designed and implemented an online, patient-completed, randomised observational trial. We will pilot it in Northwest London before national roll-out, using initially the General Practice (GP) record of a cancer diagnosis and then exploring the use of social media. The primary objective is to explore the feasibility of recruiting participants via self-identification or contact from the primary care research network and obtaining consent to link participants’ PROMs responses to their cancer registry records. Data collection occurs through a secure platform, with participants directly responsible for data entry. There is no formal target sample size because this is a feasibility study, and we want to explore how many patients we can recruit. Analyses will be conducted using descriptive statistics, repeated measures multilevel modelling and machine learning techniques. If a substantial difference in responses between randomisation arms is detected, ineffective strategies will be removed. If no clear difference is observed, recruitment will continue with periodic reviews based on response rates and data completeness.Ethics and disseminationThe Study Coordination Centre has obtained approval from the London—Surrey Research Ethics Committee and Health Research Authority. We will publish and disseminate the results in local, national and international meetings, in peer-reviewed journals, on social media and on websites.It has been registered under ‘Investigating Digital Outcomes for Cancer Survivors in the Community’ (NCT06095024).Trial registration numberNCT06095024: Investigating Digital Outcomes for Cancer Survivors in the Community.

Estimating the current global prevalence of metabolic syndrome (MetS), and its components, among rheumatoid arthritis (RA) patients is necessary in order to formulate preventative strategies and to ensure there are adequate community resources available for these patients. Furthermore, the association between RA and MetS is controversial and has not previously been comprehensively assessed. Therefore, the present study aimed to: 1) determine the prevalence of MetS, and its components, among RA patients across the world 2) update the odds ratio of MetS in RA patients, compared to healthy controls, using a comprehensive systematic review and meta-analysis. International databases, including: the Web of Science, PubMed, Scopus, Embase, CINAHL and other relevant databases were searched to identify English language articles which reported the prevalence and risk of MetS in RA patients between January 2000 and August 2016. The meta-analysis only included studies which clearly described the time and location of the study, utilised adequate sampling strategies, and appropriate statistical analyses. The meta-analyses of prevalence (70 studies [n = 12612]) and risk (43 studies [n = 35220]) of MetS in RA patients were undertaken separately. The overall pooled prevalence of MetS was 30.65% (95% CI: 27.87-33.43), but this varied from 14.32% (95% CI: 10.59-18.05) to 37.83% (95% CI: 31.05-44.61), based upon the diagnostic criteria used. The prevalence of MetS also varied slightly between males (31.94%, 95% CI: 24.37-39.51) and females (33.03%, 95% CI: 28.09-37.97), but this was not statistically significant. The overall pooled odds ratio (OR) of MetS in RA patients, compared to healthy controls, was 1.44 (95% CI: 1.20-1.74), but this ranged from 0.70 (95% CI: 0.27-1.76) to 4.09 (95% CI: 2.03-8.25), depending on the criteria used. The mean age and diagnostic criteria of MetS were identified as sources of heterogeneity in the estimated odds ratios between studies (P<0.05). According to the high prevalence of MetS in RA patients, and high risk of MetS, measuring metabolic syndrome in RA patients is strongly recommended. Furthermore, as high waist circumference (WC) is the most common metabolic syndrome component, more attention must be paid to nutrition and weight loss among those with RA.