Attention-Based Deep Recurrent Neural Network to Estimate Knee Angle During Walking from Lower-Limb EMG

Accurate prediction of joint angle during walking from surface electromyography (sEMG) offers the potential to infer movement intention and therefore represents a potentially useful approach for adaptive control of wearable robotics. Here, we present the use of a recurrent neural network (RNN) with gated recurrent units (GRUs) and an attention mechanism to estimate knee angle during overground walking from sEMG and its initial offline validation in healthy adolescents. Our results show that the attention mechanism improved estimation accuracy by focusing on the most relevant parts of the input dataset within each time window, particularly muscles active during knee excursion. Sensitivity analysis revealed knee extensor and flexor muscles to be most salient in accurately estimating joint angle. Additionally, we demonstrate the ability of the GRU-RNN approach to accurately estimate knee angle during overground walking in a child with cerebral palsy (CP) in the presence of exoskeleton knee extension assistance. Collectively, our findings establish the initial feasibility of using this approach to estimate user movement from sEMG, which is particularly important for developing robotic exoskeletons for children with neuromuscular disorders such as CP.

Claustrum sparing sign in seronegative limbic encephalitis

Background

Limbic encephalitis (LE) is a rare variant of autoimmune encephalitis. It often manifests with subacute neuropsychiatric symptoms of agitation, delusions, variable seizure semiology, and short-term memory loss. Seronegative limbic encephalitis can pose a diagnostic conundrum owing to its inadequately understood pathophysiology.

Case presentation

We report a rare case of a young male with subacute neuropsychiatric manifestations of delusions, agitations and seizures. He was diagnosed with seronegative limbic encephalitis (SNLE). Brain MRI demonstrated bilateral Claustrum sparing sign. An EEG showed continuous left-sided epileptiform discharges in periodic to predominantly left middle temporal. Patient condition gradually improved with pulsed methylprednisolone, intravenous immunoglobulins and anti-seizure medications.

Conclusion

Claustrum remains one of the least understood neuroanatomical structures. Claustrum sign has been reported in febrile infection-related epilepsy syndrome (FIRES), LE, and autoimmune refractory epilepsy. To the best of our knowledge, we report the first case in literature with Claustrum sparing sign in seronegative Limbic Encephalitis. Further experimental models and researches are warranted to better understand the unique function of the claustrum and unravel possible other attributable auto-antibodies, which could alter treatment and prognosis.

Optic cupping secondary to periventricular leukomalacia: A potential mimic for normal pressure glaucoma

We herein present a case of periventricular leukomalacia (PVL) with secondary optic pathway denervation atrophy, which was initially labeled as normal tension glaucoma. However, given the discordant clinical and ophthalmologic findings, brain magnetic resonance imaging was requested which proved PVL to be the underlying process to the patient's decreased visual acuity. In addition to presenting the ophthalmologic findings, we are emphasizing the pivotal role of neuroimaging in ruling out central causes of optic atrophy/hypoplasia and making this clinical distinction by demonstrating optic pathway atrophy associated with PVL.

The role of contemporary digital tools and technologies in COVID-19 crisis: An exploratory analysis

Following the COVID-19 pandemic, there has been an increase in interest in using digital resources to contain pandemics. To avoid, detect, monitor, regulate, track, and manage diseases, predict outbreaks and conduct data analysis and decision-making processes, a variety of digital technologies are used, ranging from artificial intelligence (AI)-powered machine learning (ML) or deep learning (DL) focused applications to blockchain technology and big data analytics enabled by cloud computing and the internet of things (IoT). In this paper, we look at how emerging technologies such as the IoT and sensors, AI, ML, DL, blockchain, augmented reality, virtual reality, cloud computing, big data, robots and drones, intelligent mobile apps, and 5G are advancing health care and paving the way to combat the COVID-19 pandemic. The aim of this research is to look at possible technologies, processes, and tools for addressing COVID-19 issues such as pre-screening, early detection, monitoring infected/quarantined individuals, forecasting future infection rates, and more. We also look at the research possibilities that have arisen as a result of the use of emerging technology to handle the COVID-19 crisis.

Case 302: Supratentorial Lymphocytic Inflammation with Parenchymal Perivascular Enhancement Responsive to Steroids

HISTORY

Part one of this case appeared 4 months previously and may contain larger images. A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and perfusion study were performed and included different sequences (Figs 1-3).

Case 302

History A 21-year-old immunocompetent man who was a long-term resident of Qatar presented to the emergency department with recurrent episodes of unprovoked generalized tonic-clonic seizures lasting 2-3 minutes that spontaneously resolved and were associated with postictal confusion. The patient also had progressive mild diplopia, intermittent dizziness, and numbness in the left arm over the course of 3 months. The patient did not have any other systemic symptoms or chronic medical diseases. He did not have any history of intake of illicit drugs, supplements, or regular medications; he had not received any recent vaccinations; and he had not undergone any surgical procedures. He had no history of travel. At presentation, vital signs were normal. Neurologic examination showed mild left homonymous hemianopia, normal gait with no cerebellar signs, and preserved sensations, power, tone, and reflexes in all four limbs. An electroencephalogram showed no epileptiform discharges. Chest CT and extensive laboratory work-up, including viral, fungal, bacterial, and parasite work-up, thyroid function tests, and immunologic blood tests yielded normal results. Those included normal complete and differential blood counts and normal serum chemistry. Serum analysis was negative for antinuclear antibody, Sjögren syndrome antigens A and B, cytoplasmic antineutrophil cvtoplasmic antibody, and paraneoplastic profile. Serum evaluation was also negative for human immunodeficiency virus type 1 and type 2 RNA, and Brucella, Schistosoma, and toxoplasma antibodies. Venereal Disease Research Laboratory (VDRL) and rapid plasma regain (RPR) test results were negative. Cerebrospinal fluid (CSF) analysis revealed clear fluid and normal pressure and biochemistry, except for elevated protein concentration (0.48 g/L) (normal range, 0.15-0.45 g/L). There were 43 leukocytes/µL (99% lymphocytes) (normal range, 0-5 leukocytes/µL; lymphocytes range, 40%-80%), with no atypical or malignant cells. CSF Gram staining, acid-fast staining, cryptococcal antigen, varicella-zoster virus polymerase chain reaction (PCR), herpes simplex virus PCR, VDRL, and RPR test results were negative. CSF cultures did not show any evidence of growth of bacteria, fungi, or acid-fast bacillus. CSF flow cytometry did not show a monoclonal lymphoid population. No CSF oligoclonal bands were detected. Conventional brain MRI with intravenous administration of contrast material and a perfusion study were performed and included different sequences (Figs 1-3).

COVID-19 related leukoencephalopathy with bilateral reticular formation involvement

We are presenting the imaging findings of COVID-19-related leukoencephalopathy associated with bilateral reticular formation diffusion restriction in brain magnetic resonance imaging. To the best of our knowledge, this is the first reported case of bilateral reticular formation affection in a COVID-19 patient.

Susceptibility-weighted Imaging in Neuroradiology: Practical Imaging Principles, Pearls and Pitfalls

Susceptibility-weighted imaging (SWI) was one of the recent and helpful advancement in magnetic resonance imaging. Its utilization -provided valuable information for the radiologists in multiple fields, including neuroradiology. SWI was able to demonstrate cerebral paramagnetic and diamagnetic substances. Therefore, the applications of this imaging technique were diverse in research and clinical neuroradiology. This article reviewed the basic technical steps, various clinical applications of SWI, and potential limitations. The practicing radiologist needs to be oriented about using SWI and phase images in the right- and left-handed MRI systems to demonstrate different brain pathologies, including neurovascular diseases, traumatic brain injuries, brain tumors, infectious and inflammatory, and neurodegenerative diseases.

Bilateral Thalamic Infarction Secondary to Thrombosis of Artery of Percheron

The artery of Percheron (AOP) is a rare anatomical variation emerging from the posterior circulation and supplies both thalami in the brain. As per the literature, the AOP infarction constitutes less than 2% of all stroke cases. AOP infarctions are usually caused by a combination of risk factors and a predisposing vascular territory. The areas most affected by AOP are the paramedian thalami with or without the involvement of the midbrain. AOP can be challenging as it is infrequent and mostly can be missed on the initial scans. We present a 58-year-old previously healthy male known to have hypertension with poor follow-up who presented with dysarthria and facial weakness, which he felt after waking up from sleep. After the initial physical examination and investigations, a preliminary diagnosis of stroke was made. As the patient was worked up for the stroke, his symptoms improved, and he was back to his baseline function within 48 hrs of presentation. What came to our surprise was that the stroke workup, including the initial CT scan with an angiogram, blood works (Hba1c and lipid panel), echocardiogram of the heart (ECHO), and Holter monitor was all unremarkable until an MRI head was done, which showed bilateral thalamic acute-sub acute infarct. This shows that AOP can be easily missed as it may not appear on the initial scans and workup and needs an adequate radiological study for diagnosis. Although some cases of AOP infarction are reported in the literature, the presentation with transient mild symptoms makes our case an interesting one.

Assessment of Conventional Solvent Extraction vs. Supercritical Fluid Extraction of Khella (Ammi visnaga L.) Furanochromones and Their Cytotoxicity

Background: Khella (Ammi visnaga Lam.) fruits (Apiaceae) are rich in furanochromones, mainly khellin and visnagin, and are thus incorporated in several pharmaceutical products used mainly for treatment of renal stones. Methods: The objective of this study was to compare the yield of khellin and visnagin obtained using different conventional solvents and supercritical fluid extraction (SCFE) with carbon dioxide (containing 5% methanol as co-solvent). Water, acetone and ethanol (30% and 95%) were selected as conventional solvents. Results: Highest extract yield was obtained from 30% ethanol (15.44%), while SCFE gave the lowest yield (4.50%). However, the percentage of furanochromones were highest in SCFE (30.1%), and lowest in boiling water extract (5.95%). HPLC analysis of conventional solvent extracts showed other coumarins that did not appear in supercritical fluid extraction chromatogram due to non-selectivity of solvent extraction. Ammi visnaga extracts as well as standard khellin and visnagin were tested for their cytotoxic activity using sulforhodamine B assay on breast cancer (MCF-7) and hepatocellular carcinoma (Hep G2) cell lines. Results revealed a strong cytotoxic activity (IC₅₀ < 20 µg/mL) for the SCFE and standard compounds (khellin and visnagin) (IC₅₀ ranging between 12.54 ± 0.57 and 17.53 ± 1.03 µg/mL). However, ethanol and acetone extracts had moderate cytotoxic activity (IC₅₀ 20–90 µg/mL) and aqueous extract had a weak activity (IC₅₀ > 90 µg/mL). Conclusions: Thus, supercritical fluid extraction is an efficient, relatively safe, and cheap technique that yielded a more selective purified extract with better cytotoxic activity.

Spinal cord infarction in a 41-year-old male patient with COVID-19

The severe acute respiratory syndrome coronavirus disease 2019 (COVID-19) pandemic, became rapidly recognised by variable phonotypic expressions that involve most major body organs. Neurological complications of severe acute respiratory syndrome coronavirus disease are increasingly encountered in patients with COVID-19 infection, more frequently in patients with severe infection, and develop as a consequence of the neurotropic potential of this virus, secondary cytokine storm and acquired syndrome of COVID-19 coagulopathy. Spinal cord involvement after COVID-19 more commonly includes infectious transverse myelitis, para and post infection myelopathy and, rarely, spinal cord ischaemia related to increased coagulopathy with thromboembolic consequences. We herein report a COVID-19-positive patient with increased coagulopathy and vertebral artery thrombosis leading to posterior circulation and subsequent spinal cord infarction.

Spectrum of neuroimaging findings in COVID-19

An outbreak of corona virus disease 2019 (COVID-19) began in China in December 2019, and rapidly spread to become a worldwide pandemic. Neurological complications encountered in hospitalized patients include acute arterial ischemic cerebrovascular stroke, cerebral venous thrombosis, critical illness-associated cerebral microbleeds, hypertensive hemorrhagic posterior reversible encephalopathy, meningoencephalitis/flare up of infections, flare up of multiple sclerosis, acute disseminated encephalomyelitis, cerebral hemodynamic/hypoxic changes such as watershed ischemic changes and hypoxic ischemic encephalopathy, and spine manifestations of Guillain Barre syndrome and viral myelitis. The purpose of our study is to illustrate the different neuroimaging features in critically ill hospitalized COVID-19 positive patients in the State of Qatar.

Critical illness-associated cerebral microbleeds in COVID-19

We are reporting the imaging findings of the rare entity of critical illness-associated cerebral microbleeds in a COVID-19-positive 66-year-old woman with hypoxic respiratory failure, who was eventually intubated and ventilated. Multiple scattered cerebral microhaemorrhages diffusely distributed in the juxtacortical white matter and internal capsule region, sparing the deep and periventricular white matter, basal ganglia, thalami and cortex were seen, which is a unique imaging finding in critically ill patients with respiratory failure and hypoxemia requiring mechanical ventilation. The mechanism underlying these microhaemorrhages relates to the endpoint of critical illness, rather than a specific underlying disease.

Genome-wide association study of psoriasis in an Egyptian population

Psoriasis is a chronic inflammatory disorder of the skin, with genetic factors reportedly involved in the disease pathogenesis. Numerous studies reported psoriasis candidate genes. However, these tend to involve mostly in the European and Asian populations. Here, we report the first genome-wide association study (GWAS) in an Egyptian population, identifying susceptibility variants for psoriasis using a two-stage case-control design. In the first discovery stage, we carried out a genome-wide association analysis using the Infinium^® Global Screening Array-24 v1.0, on 253 cases and 449 control samples of Egyptian descent. In the second replication stage, 26 single-nucleotide polymorphisms (SNPs) were selected for replication in additional 321 cases and 253 controls. In concordance with the findings from previous studies on other populations, we found a genome-wide significant association between the MHC locus and the disease at rs12199223 (P_comb  = 6.57 × 10^-18 ) and rs1265181 (P_comb  = 1.03 × 10^-10 ). Additionally, we identified a novel significant association with the disease at locus, 4q32.1 (rs12650590, P_comb  = 4.49 × 10^-08 ) in the vicinity of gene GUCY1A3, and multiple suggestive associations, for example rs10832027 (P_comb  = 7.28 × 10^-06 ) and rs3770019 (P_comb  = 1.02 × 10^-05 ). This proposes the existence of important interethnic genetic differences in psoriasis susceptibility. Further studies are necessary to elucidate the downstream pathways of the new candidate loci.

A Rare Case of Choroid Plexus Papilloma of the Third Ventricle in an Adult

Colloid cysts are the commonest masses of the third ventricle. Third ventricle neoplasms are uncommon. They include tumors arising from the choroid plexus (papillomas, carcinomas), tumors arising from other than the choroid plexus (ependymomas, meningiomas), metastases, and lymphoma. Choroid plexus tumors usually occur in the lateral ventricle in children and fourth ventricle in adults, and often present with hydrocephalus. We herein describe the extremely rare occurrence of third ventricle choroid plexus papilloma in a 35-year-old man who presented to the emergency department with a long history of intermittent headaches, occasionally associated with photophobia. CT and MR imaging revealed a lobulated ovoid lesion in the third ventricle with minimal extension into the right lateral ventricle through the foramen of Monro, causing mild ventricular dilatation. Surgical resection was performed and histopathology revealed choroid plexus papilloma.

Acute Flaccid Myelitis in COVID-19

Spinal cord imaging findings in COVID-19 are evolving with the increasing frequency of neurological symptoms among COVID-19 patients. Several mechanisms are postulated to be the cause of central nervous system affection including direct virus neuroinvasive potential, post infectious secondary immunogenic hyperreaction, hypercoagulability, sepsis and possible vasculitis as well as systemic and metabolic complications associated with critical illness. Only a few case reports of spinal cord imaging findings are described in COVID-19, which include transverse myelitis, acute disseminated encephalomyelitis and post-infectious Guillain Barre’ syndrome. We are describing a case of myelitis which, to the best of our knowledge, is the first reported case of myelitis in COVID-19.

Follicular Unit "Exploitation": Follicular Unit Extraction Followed by Laser Hair Reduction-A Novel Approach to Repigmentation of Postburn Leukodermic Scars

Correction of depigmentation of postburn leukodermic scars is daunting. In contrast to vitiligo, the success rate of skin grafting techniques is much lower in postburn scars owing to altered skin architecture and poor graft uptake. Cellular transfer techniques such as noncultured epidermal or epidermal or keratinocyte suspension suffer the limitations of modest efficacy and high procedural cost. Follicular transplantation by the follicular unit extraction technique is being extensively used in vitiligo. Recently, it has been reported for the correction of scar alopecia. Although this approach is expected to significantly repigment pliant scars, the cosmetic unacceptability of the retained hairs may warrant removal. We describe an innovative three-step protocol to provide a repigmented smooth scar. We vernacularly labeled this technique follicular unit “exploitation,” as the follicular units “exploited” positively for repigmentation were later removed by laser hair reduction.

Quality of Life of Egyptian Cancer Patients in Relation With the Types and Quality of Information Given

Background: The concept of quality of life (QOL) refers to the ability to enjoy normal life activities; it is a complex combination of satisfactory functioning in essential four core domains — physical, psychological/emotional, social and quality of life is an important aspect of care in the clinical setting; nurses can improve patients´ quality of life by ensuring they are competent in daily practice, and by giving patients a high quality holistic care based on safe, effective intervention and providing required information. Aim: To evaluate the quality of life of cancer patients in relation to different treatment modalities and evaluate the impact of the information given on the quality of life. Methods: A convenient sample of adult cancer patients recruited from a university hospital, Cairo, Egypt. Data were collected through self-administered questionnaire or patient structured interview. Tools used: EORTC QLQ-C30 (Version 3) and QLQ-INFO25. Data analysis includes descriptive statistics and exploration of relationships between key variables; physical, emotional, social well-being, type of treatment, information given and quality of life. Results: Preliminary results revealed significant correlation between fatigue, emotional disturbance and quality of life. Lack of information is also correlated with low quality of life. Patients expressed their needs for more clarification about treatment, coping with disease and future consideration. Conclusion: Quality of life should be assessed frequently by nurses throughout treatment phases to identify patients at risk. Nurses also should emphasize on proper patients teaching and counseling to promote physical psychosocial balance and improve quality of life.

Studies on the protective effect of the artichoke (Cynara scolymus) leaf extract against cadmium toxicity-induced oxidative stress, hepatorenal damage, and immunosuppressive and hematological disorders in rats

Our objective was to explore the protective effect of artichoke leaf extract (ALE) against cadmium (Cd) toxicity-induced oxidative organ damage in rats. Male albino Wistar rats were divided into four equal groups of eight animals each. The first group was assigned as a control. Groups 2-4 were orally administered with ALE (300 mg/kg bw), Cd (CdCl₂, 100 mg/L drinking water), and ALE plus Cd, respectively, daily for 4 weeks. After treatment with Cd, the liver and kidney malondialdehyde (MDA) increased significantly compared with the control rats. The sera interleukin (IL)-1β, tumor necrosis factor (TNF-α), and IL-10, liver transaminase, urea, creatinine, and peripheral neutrophil count were significantly increased in Cd-exposed rats compared to the control group. The reduced glutathione (GSH), glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) decreased in the liver and kidney in Cd-exposed group. In combination treatment, Cd and ALE significantly improved immune response, an antioxidant system, and hepatorenal function with a significant decline in MDA. In conclusion, ALE ameliorates the immunosuppressive and hepatorenal oxidative injury stimulated by Cd in rats. These results suggest that artichoke has shown promising effects against adverse effects of Cd toxicity.

Medullary carcinoma of the breast: ten year clinical experience of the Kuwait cancer control centre

BACKGROUND

Medullary carcinomas of the breast account for fewer than 7% of all invasive breast cancers. Some investigators include medullary carcinomas in the favourable histologic subtype, despite its aggressive histologic appearance. However, others fail to confirm its favourable prognosis.

METHODS

This was a retrospective analysis of sixty-one (61) cases of breast cancer cases diagnosed with Medullary Carcinoma, presenting to the Kuwait Cancer Control Center between 1995 and 2005.

RESULTS

Median survival time was 122 months and the seven-year disease free survival was 82%. Overall survival rate was not assessed as no cases died during the study period. No cases were metastatic from the start and only eight cases developed metastases, local recurrence or contralateral breast primary. 68.8% of the cases were Stage I or IIA (i.e. no lymph node affection).

CONCLUSION

There is no overt favourable prognosis of medullary carcinoma when compared to invasive ductal carcinoma. Prognosis is more related to stage than histologic subtyping. The majority of cases were negative estrogen and progesterone receptor status and node negative.

Randomized trial comparing cryoablation and external beam radiotherapy for T2C-T3B prostate cancer

The objective was to evaluate the relative efficacy of cryoablation (CRYO) versus external beam radiation (EBRT) for clinically locally advanced prostate cancer in a randomized clinical trial. Patients with histologically proven, clinically staged as T2C, T3A or T3B disease were randomized with 6 months of perioperative hormone therapy to one of the two procedures. Owing largely to a shift in practice to longer term adjuvant hormonal therapy and higher doses of radiation for T3 disease, only 64 out of the planned 150 patients were accrued. Twenty-one of 33 (64%) in the CRYO group and 14 of 31 (45%) in the EBRT-treated group who had met the ASTRO definition of failure were also classified as treatment failure. The mean biochemical disease-free survival (bDFS) was 41 months for the EBRT group compared to 28 months for the CRYO group. The 4-year bDFS for EBRT and CRYO groups were 47 and 13%, respectively. Disease-specific survival (DSS) and overall survival (OS) for both groups were very similar. Serious complications were uncommon in either group. EBRT patients exhibited gastrointestinal (GI) adverse effects more frequently. Taking into account the relative deficiency in numbers and the original trial design, this prospective randomized trial indicated that the results of CRYO were less favorable compared to those of EBRT, and was suboptimal primary therapy in locally advanced prostate cancer.

Parameters of successful sacral root neuromodulation of the pelvic floor: a retrospective study

INTRODUCTION/OBJECTIVE

Neuromodulation of the pelvic floor (InterStim) is a relatively new technique in the field of urology. We present our observations for effective neuromodulation on our patient population.

MATERIALS AND METHODS

In a retrospective case review study, we studied the charts of 67 patients, who underwent InterStim operations between the years 1993 to 2002. All patients had a good response to InterStim. Patients with inefficient or inconclusive responses were not included in the study. All the relevant patient data was recorded from their charts. For each patient, the following was recorded; the amplitude in volts, the pulse width (in microseconds) and rate, the mode (cycling versus continuous), the electrodes and their position, the load impedance, and the change in amplitude over time.

RESULTS

Amplitude over time showed an initial plateau, followed by a small increase that gets larger.

CONCLUSIONS

Long-term management of InterStim recipients requires increasing amplitude following the implantation of the IntreStim to maintain the same satisfactory levels of urinary control.

Update on sacral neuromodulation: Indications and outcomes

Tanagho and Schmidt first introduced sacral nerve neuromodulation in 1981. Since then, it has become increasingly popular and the indications for this procedure are growing. The purpose of this article is to discuss the established indications for sacral nerve stimulation (SNS). The outcomes of the most recent studies and trials dealing with SNS are presented. An overview of the most recent techniques used for neuromodulation is detailed.