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PubMed1995

[Disorders of bladder function in the elderly].

Voiding dysfunction in elderly patients is not a uniform disease entity. Diseases of the cerebrospinal system, metabolic imbalances, detrusor degeneration and bladder outlet obstruction or sphincter impairment can all result in disabilities such as urinary retention and/or urinary incontinence. Although the urodynamic pattern of an uninhibited neuropathic bladder resulting from a poorly functioning corticoreticular system may seem to be normal in these elderly subjects, many of them have lost control of the micturition reflex: the warning to void occurs suddenly at full bladder capacity, and the abrupt sensation that urination is imminent cannot be controlled appropriately. Classifying these symptoms under a simple common denominator, such a detrusor instability can be misleading, because the therapeutic approach in these patients should be more highly differentiate. Detrusor overactivity may be symptomatic and associated with curable diseases of the lower urinary tract, such as bladder outlet obstruction, urinary tract infection or bladder cancer. On the other hand, some of the underlying causes of so-called idiopathic detrusor overactivity have been disclosed recently by Elbadawi et al. (1993), relating detrusor impairment to detrusor degeneration characterized morphologically by a dysjunction pattern. In this setting, it cannot be overemphasized that better knowledge of the underlying disease will result in more successful treatment of the voiding disability in such patients. Urinary incontinence in elderly patients is not always due to an incompetent urinary sphincter, and urinary retention in this age group is not always the result of a bladder outlet obstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed2006

[Modified sacrocolpopexy combined with a Burch procedure for recurrent stress urinary incontinence].

PURPOSE: Surgical procedures for the treatment of stress urinary incontinence (SUI) due to pelvic organ prolapse have specific relapse rates, especially with regard to long-term results. The aim of this study was to investigate the efficacy of a combined surgical technique: sacrocolpopexy combined with a Burch procedure - in particular as an option for previously operated patients. PATIENTS AND METHODS: From 9/2001 to 8/2004, 33 patients (mean age: 65 years) underwent a modified sacrocolpopexy combined with a Burch procedure. Thirty-six (93 %) patients had previous pelvic operations, nineteen (58 %) of them had failure of prior prolapse surgery. All women presented with urinary incontinence, cystocele and vault prolapse. SUI was classified grade II to III in 67 % (n = 22) cases. Grade II - III genital prolapse was associated in 88 % (n = 29) of the patients. They were screened by preoperative video-urodynamics. Surgery consisted of a Burch procedure and modified abdominal sacrocolpopexy. The mean follow-up was 18 months (range: 10 - 30 months). Follow-up investigations included a symptom score and an urogynaecological examination. A subgroup of ten patients had additional postoperative video-urodynamics. RESULTS: In all cases the operative procedure was performed successfully. During the follow-up 73 % (n = 24) of the patients were dry, another 18 % (n = 6) showed significant improvement. The number of diurnal/nocturnal micturitions decreased significantly from 9.4 to 6.9 (p < 0.005) and 2.2 to 1.1 (p < 0.005), respectively. The daily use of incontinence pads, as well as the amount of residual urine, decreased significantly from n = 5.1 to n = 1.1 (p < 0.005) and 60 mL to 6.0 mL (p < 0.005). Postoperative urodynamics showed that the bladder function remained unaffected by the procedure regarding de novo detrusor overactivity. CONCLUSION: After a mean follow-up of 18 months the modified sacrocolpopexy combined with a Burch procedure, as described above, is a promising technique for highly morbid and preoperated patients.

Aged↗

PubMed2006

Reduction of moderate-to-large cystocele during urodynamic evaluation using a vaginal gauze pack: 8-year experience.

OBJECTIVE: To determine the effect of cystocele reduction by a vaginal gauze pack on urodynamic studies (UDS). PATIENTS AND METHODS: UDS from consecutive women with symptomatic pelvic organ prolapse were reviewed. The protocol included a 'fill-void' study with a vaginal gauze pack, and then repeated without the pack. Tracings were categorized based on filling cystometrograms (CMGs) and pressure-flow studies (PFS). RESULTS: Of 202 women, 121 with a mean (sd) age of 67 (9.4) years contributed 221 interpretable 'pack, then no-pack' UDS (111 CMGs and 110 PFS); 77 of the women had a moderate cystocele and 44 had a large cystocele. Eighty-five women had urethral hypermobility (UH), and 36 had a well-supported urethra (WSU). The pack unmasked stress urinary incontinence (SUI) in 6% of women, with a mean (sd, range) Valsalva leak-point pressure of 54 (22, 23-90) cmH(2)O. SUI occurred more often in women with UH than WSU. Detrusor overactivity occurred similarly in pack (15%) and no-pack (14%) tracings. Bladder outlet obstruction (BOO) was relieved by the pack in 25 studies and caused by the pack in four. Women with WSU had BOO more often than those with UH (43% vs 22%, P < 0.05), regardless of the presence or absence of the pack. CONCLUSION: Unmasked SUI by pack reduction was uncommon, presumably due to anterior vaginal wall stabilization, as the pack rarely caused BOO. Those with SUI had Valsalva leak-point pressures suggestive of intrinsic sphincter deficiency. The pack did not significantly influence the presence of detrusor overactivity.

Adult↗

PubMed2006

Bladder and external urethral sphincter function after prenatal closure of myelomeningocele.

PURPOSE: We compared urodynamic findings in patients who underwent prenatal closure of myelomeningocele with those of patients who underwent postnatal closure, and equivalent lower urinary tract evaluations. MATERIALS AND METHODS: Urodynamic studies of 5 patients (2 boys, 3 girls) who underwent prenatal closure of myelomeningocele were compared to those of 88 patients with similar level lesions who underwent repair postnatally between 1979 and 2002. RESULTS: All 5 patients in the prenatally treated cohort had lower lumbosacral lesions on neurological examination. These patients displayed no evidence of electromyographic activity, indicating complete denervation of the external sphincter. In comparison 34 of the 88 patients in the postnatal cohort (39%) lacked sphincter activity at newborn examination, with similar findings noted at 1-year evaluation. In terms of bladder function all 5 patients in the prenatal cohort exhibited detrusor overactivity, compared to 33 of the 88 patients (38%) in the postnatal cohort at the newborn examination, with similar findings at 1-year evaluation. CONCLUSIONS: Fetal closure of myelomeningocele is associated with a higher incidence of complete denervation of the external urethral sphincter and detrusor overactivity compared to postnatal closure. Patients who undergo this novel procedure should undergo urodynamic studies in the immediate newborn period and should be under close postnatal surveillance to document possible tethering of the spinal cord, urinary incontinence and increased detrusor pressures.

Child, Preschool↗

PubMed1982

Flexor reflex control of the external sphincter of the urethra in paraplegia.

In paraplegics and quadriplegics a profound paralysis of skeletal muscles occurs below the level of the spinal lesion. Unexplained in this state is the development of an overactive external urethral sphincter, which interferes with emptying of the bladder and may lead to infection of the urinary tract. Studies of cats show that the discharge of motoneurons causing this contraction has all the characteristics of a flexor reflex.

Animals↗

PubMed2004

Urodynamic findings in adults with primary nocturnal enuresis.

PURPOSE: We evaluate bladder function in adults with primary nocturnal enuresis (PNE) since childhood. MATERIALS AND METHODS: We recruited all patients older than 16 years who presented to our PNE clinic with persistent enuretic symptoms. All patients were assessed by a detailed voiding diary, uroflowmetry and ultrasonography of the urinary tract. Urodynamic studies were performed for those with moderate or severe PNE (more than 3 wet nights a week). RESULTS: The study included 18 males and 29 females with a mean age of 20 years (range 16 to 43). Of these patients 37 (79%) had moderate or severe symptoms and 17 (38%) also had daytime urinary symptoms. Urodynamic studies were conducted in 30 patients, including 12 males and 16 females (93%) with detrusor overactivity. In addition, 73% of patients had urodynamic evidence of functional bladder outflow obstruction, including dysfunctional voiding and detrusor sphincter or detrusor pelvic discoordination. Two male patients (6.7%) had an obstructive pattern on urodynamics and subsequent cystoscopic examination confirmed the presence of congenital obstructive urethral lesions. Sixteen patients (53%) had significantly reduced bladder capacity of less than 300 ml. CONCLUSIONS: Unlike in early childhood, the majority (79%) of enuretic adults had significant symptoms, and more than a third also had daytime urinary symptoms. We believe that PNE in adults is not only a psychologically disturbing condition, but also a urological disorder with significant underlying bladder dysfunction that warrants special attention to management.

Adolescent↗

PubMed2000

Voiding dysfunction and Parkinson's disease: urodynamic abnormalities and urinary symptoms.

PURPOSE: We evaluated bladder dysfunction and Parkinson's disease in regard to disease severity and determined whether subjective patient urinary symptoms correlated with urodynamic abnormalities. MATERIALS AND METHODS: We assessed bladder dysfunction in 70 patients with Parkinson's disease and urinary symptoms using the International Prostate Symptom Score and urodynamic tests. RESULTS: Urodynamic evaluation revealed detrusor hyperreflexia in 47 patients (67%), hyporeflexia or areflexia in 11 (16%), hyperreflexia with impaired contractile function in 6 (9%), hyperreflexia with detrusor-sphincter dyssynergia in 2 (3%) and normal function in 4 (6%). The incidence of urodynamic abnormalities appeared to increase with disease severity. However, the only urodynamic parameter that correlated with disease severity was post-void residual urine volume. On the other hand, symptom index scores increased with disease severity. The irritative symptom score correlated with maximum cystometric capacity and volume at initial desire to void, whereas the obstructive symptom score correlated with post-void residual urine volume. Also, irritative and obstructive scores were good predictors of overactivity during the storage and underactivity at the voiding phases. CONCLUSIONS: Bladder function may deteriorate progressively with advancing disease. Symptom scores are fairly accurate for predicting likely urodynamic abnormalities. Our results imply that quantifying subjective urinary symptoms is useful for estimating the severity and type of bladder dysfunction.

Adult↗

PubMed1988

Long-term follow-up of selective sacral neurectomy.

Between 1976 and 1981, 22 patients underwent selective, complete sacral root section as a treatment for severe detrusor overactivity. Eighteen were followed up for more than 4 years (mean 6.2). Thirteen of the 22 patients had significant symptomatic improvement lasting for more than 4 years post-operatively (59%), 8 of whom had stable bladders. It was concluded that this operation still has a place in the treatment of detrusor overactivity.

Adolescent↗

PubMed2003

Urodynamics prior to renal transplantation--its impact on treatment decision and final results.

OBJECTIVE: To evaluate the role of urodynamics prior to renal transplantation in a selected group of patients. MATERIAL AND METHODS: This retrospective study included 44 consecutive patients (20 males, 24 females; age range 7-57 years; mean age 27.14 +/- 15.17 years) referred for urodynamic evaluation due to known or suspected lower urinary tract dysfunction. End-stage renal disease was due to obstructive uropathy in nine patients, reflux nephropathy in 13, neuropathic bladder in nine and various parenchymal diseases in four; in nine patients the origin of renal failure remained obscure despite detailed investigations. All the patients were subjected to detailed video-urodynamics. RESULTS: In 30 patients (68.2%) a urodynamic abnormality was found which precluded kidney transplantation into their native bladders without major reconstruction, a minor corrective procedure and/or pharmacotherapy prior to transplantation. More specifically, seven patients were found to have infravesical obstruction, one had a small fibrotic bladder, seven had small capacity bladders due to long-term non-use, four were found on cystometry to have an idiopathic overactive detrusor and 11 exhibited evidence of neurogenic lower urinary tract dysfunction. Fourteen affected patients (32%) were subjected to treatment prior to kidney transplantation: three underwent bladder neck incision, seven recycling of their small bladders, one substitution and three augmentation cystoplasty. Kidney transplantation followed reconstruction 3-18 months later (mean 5 +/- 6.2 months). The follow-up ranged from 12 to 107 months (mean 25 +/- 21 months). CONCLUSION: Urodynamics prior to kidney transplantation in this selected group of patients established a definitive diagnosis of the type of lower urinary tract dysfunction, offered the opportunity for reconstructive surgery and enabled kidney transplantation.

Adolescent↗

PubMed1999

Bladder involvement in Behçet's syndrome.

PURPOSE: We report our clinical experience with Behçet's syndrome and bladder involvement. MATERIALS AND METHODS: From April 1991 through July 1996, 7 men and 1 woman 25 to 53 years old with Behçet's syndrome were evaluated for lower urinary tract symptoms (7) or hematuria (1). Of 8 patients 5 had neurological involvement. Evaluation consisted of history, physical examination, urinalysis and urine culture, excretory urography, urodynamic studies, urethrocystoscopy, bladder biopsies and histopathological examination. RESULTS: Cystoscopy revealed bladder ulcer in 1 patient and an indurated, hypervascular lesion in another with bilateral hydronephrosis. The most common urodynamic finding was detrusor overactivity. Of 4 patients with poor compliance 1 had additional sphincteric deficiency. Common histopathological features were moderate and marked thickening of bladder vessel walls. Lymphocytic vascular reaction was present in 2 patients and lymphocytic vasculitis in 1. Clamshell augmentation ileocystoplasty was performed in 3 patients, including 1 who also underwent a sphincter enhancement procedure. The remaining 5 patients received various nonsurgical treatment. CONCLUSIONS: Various types of voiding dysfunction relating to bladder and sphincteric components in both phases of micturition can be seen in Behçet's syndrome. Voiding dysfunction can be due to either neurological or direct bladder involvement. Augmentation ileocystoplasty is a good treatment option for Behçet's syndrome with severe bladder involvement.

Adult↗

PubMed2006

Voiding dysfunction and the Williams-Beuren syndrome: a clinical and urodynamic investigation.

PURPOSE: WBS is an autosomal dominant disorder that includes features such as developmental delay, cardiovascular anomalies, mental retardation and characteristic facial appearance. We systematically investigated the prevalence and spectrum of voiding dysfunction in this population. MATERIALS AND METHODS: We prospectively evaluated 16 boys and 12 girls with WBS, with a mean age of 9.7 years (range 3 to 19). Urological evaluation included history of urinary symptoms and impact on quality of life, voiding diary, urodynamics and radiological evaluation with urinary tract sonography, voiding cystourethrography and renal scintigraphy. RESULTS: A total of 22 patients (78.6%) were symptomatic, including 15 (53.6%) with a significant negative impact on the quality of life. Increased urinary frequency was the most common complaint, present in 17 patients (60.7%), followed by enuresis (50%) and urge incontinence (42.8%). A total of 14 patients (50%) had urinary tract abnormalities, with bladder diverticula as the predominant anomaly (10 of 23 patients, or 43.5%). Urodynamics revealed detrusor overactivity in 17 patients (60.7%), detrusor-sphincter dyssynergia with detrusor overactivity in 4 (14.3%) and detrusor-sphincter dyssynergia without detrusor overactivity in 2 (7.1%). An average reduction of 28.3% of the cystometric capacity in comparison to expected capacity for age was found (p <0.001). Urodynamic abnormalities were significantly associated with the presence of voiding symptoms (p = 0.003) and bladder diverticula (p = 0.001). CONCLUSIONS: Children with the Williams-Beuren syndrome are at high risk for presenting with voiding dysfunction and structural abnormalities, and should undergo a minimum evaluation that includes voiding history and urinary tract sonography, while urodynamics, VCUG and additional studies should be performed in symptomatic patients or those whose initial evaluation shows significant abnormalities.

Adolescent↗

PubMed2005

Preliminary communication: urodynamic assessment of donepezil hydrochloride in patients with Alzheimer's disease.

BACKGROUND AND AIMS: Donepezil hydrochloride, a central cholinergic drug, is widely used for improving cognitive decline in Alzheimer's disease (AD). We investigated whether donepezil might affect the lower urinary tract (LUT) function in AD. METHODS: Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) (0-70, increase as impairment), urinary questionnaire, and electromyography (EMG)-cystometry were performed in eight patients with AD before and after treatment with 5 mg/day of donepezil. RESULTS: The first assessment (before donepezil) showed moderate cognitive decline in the patients as a mean ADAS-cog score of 27.0 (range: 17-35) (normal < 15). Seven patients had urinary symptoms including urinary urgency incontinence in five. EMG-cystometry revealed neurogenic detrusor overactivity in seven with a mean detrusor pressure of 44.9 cm H(2)O (20-101), mean bladder capacity of 202 ml (20-412), and post-void residuals in none. The second assessment (3 months after donepezil) showed a decrease in the ADAS-cog score to 23.3 (11-35) though without statistical significance. Urinary incontinence disappeared in one and none had a new onset of incontinence. EMG-cystometry revealed an increase in the detrusor pressure on overactivity to 54.1 cm H(2)O (20-122), but also an increase in the bladder capacity to 234 ml (80-400), and post-void residuals in one (40 ml). CONCLUSION: Although the number of our patients was small, it seems possibly that donepezil could ameliorate cognitive function without serious adverse effects on the LUT function in patients with AD.

Aged↗

PubMed2006

When to use antimuscarinics in men who have lower urinary tract symptoms.

Although alpha-blockers are commonly used and generally effective in men who have symptomatic bladder outlet obstruction (BOO), a subset of these patients who have detrusor overactivity (DOA) often complain of persistent symptoms even after alpha-blocker therapy. What are the barriers to using antimuscarinics induce additional benefit? Should these men be treated primarily with antimuscarinics? The authors review several recent publications that look at this important issue and discuss when antimuscarinics should be used. It appears that BOO with concomitant DOA can be safely and accurately treated with a combination of alpha-blockers and antimuscarinics.

Humans↗

PubMed2006

Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men.

OBJECTIVES: To review and characterize two groups of men who report being pad-free after robot-assisted laparoscopic prostatectomy (RLRP): those with occasional incontinence and those with complete control. METHODS: The study included 106 out of a total of 195 men who underwent RLRP. Inclusion requirements were adequate follow-up and no-pad continence status. All patients completed self-administered American Urological Association symptom score (AUAss) and continence questionnaires and underwent measurement of peak urinary flow rates, postvoid residual volumes, and voided volumes (VV) before and 3 months after surgery. All data and standard clinical characteristics were entered prospectively into an electronic database. RESULTS: Two distinct groups reported wearing no pads: the "perfect" group (n = 32) reported never leaking, and the "imperfect" group (n = 74) reported occasional leakage but did not wear pads. Preoperatively, the "imperfect" group was older (62.2 versus 59 years) and had more urinary symptoms (all P < 0.05). Postoperatively, the "imperfect" group took longer to achieve a pad-free status (median 39.8 versus 19.3 days), had larger prostates (mean 50.9 versus 43.2 g), had lower VV (324 versus 405 mL), and more urinary symptoms (AUAss 7.4 versus 4.3; all P < 0.05). CONCLUSIONS: Sixty-nine percent of men who attain "pad-free continence" after RLRP have occasional urinary leakage. Preoperatively, these men are characteristically older and have larger prostates, AUAss, and bother scores. Postoperatively, the "imperfect" group takes longer to achieve pad-free status and has smaller bladder capacities and more urinary symptoms. These results suggest that an overactive detrusor is the likely contributing etiology.

Humans↗

PubMed2002

Effect of spinal cord abnormalities on the function of the lower urinary tract in patients with anorectal abnormalities.

PURPOSE: We evaluated the effect of spinal cord abnormalities on lower urinary tract function in patients with anorectal abnormalities. MATERIALS AND METHODS: We examined 30 patients with anorectal anomalies mainly because of fecal or urinary incontinence. All patients underwent spinal magnetic resonance imaging and urodynamic investigation. RESULTS: Major lumbosacral abnormalities were detected in 57% of patients, including 13, 4 and 3 with a tethered cord, syringomyelia and caudal regression, respectively. Significant dysfunction of the lower urinary tract in 57% of the cases involved an overactive detrusor in 11, detrusor-sphincter dyssynergia in 4, distended bladder in 4 and lazy bladder in 1. When the spinal cord was normal, 54% of the patients had abnormal urodynamic findings but when the spinal cord was abnormal, 59% had abnormal urodynamics. When the bony spine was normal, 33% of the patients had an abnormal spinal cord but when the bony spine was abnormal, 69% had an abnormal spinal cord. CONCLUSIONS: Patients with anorectal abnormalities and fecal or urinary incontinence problems often have an abnormal spinal cord and abnormal urodynamic findings. However, the state of the spinal cord is not the only factor explaining lower urinary tract function. Thus, the possibility of lower urinary tract dysfunction should be considered in each patient with anorectal abnormalities. If the patient has symptoms or findings suggesting abnormal lower urinary tract function urodynamic evaluation should be performed.

Adolescent↗

PubMed2003

Innervation of the detrusor muscle bundle in neurogenic detrusor overactivity.

OBJECTIVE: To evaluate the peripheral anatomical distribution of innervation within muscle bundles of the detrusor and the changes arising in neurogenic detrusor overactivity (DO). PATIENTS AND METHODS: Full-thickness samples from the bladder dome of three cadaveric transplant organ donors and four people with neurogenic DO caused by spinal cord injury were compared. Systematic serial cryostat sections were stained using Masson trichrome and elastin techniques, and vimentin immunohistochemistry. A coherent image stack was generated for three-dimensional image reconstructions, which were displayed using mixed rendering (i.e. differing graphics for separate tissue components) to show peri- and intra-bundle innervation against the muscle fascicle framework. RESULTS: Control specimens had a dense nerve supply. Muscle bundle innervation was derived by dichotomous branching from peri-bundle nerve trunks in the inter-bundle connective tissue. Transverse interfascicular branches entered bundles perpendicular to the long axis at the midpoint of the bundle. They gave rise to axial interfascicular branches, which distributed to the pre-terminal and terminal nerve fibres. All samples from patients with neurogenic DO had patchy denervation. The primary deficit was predominantly at the level of the terminal axial innervation and was cross-sectionally consistent along the longitudinal axis of the muscle bundle. CONCLUSION: Patchy denervation may reflect a deficit at the level of the peripheral ganglia. Any contraction in the areas of denervation either occurs out of co-ordination with the rest of the bladder, or is co-ordinated by means of non-neural structures. The observation of fine muscle strands running between fascicles, and connective tissue anchoring structures, represent two hypothetical mechanisms by which such co-ordination might be effected.

Adult↗

PubMed2005

Five years follow up of laparoscopic burch colposuspension for stress urinary incontinence in Thai women.

OBJECTIVES: To study the cure rate and 5 year results of laparoscopic burch colposuspension for stress urinary incontinence in Thai women. MATERIAL AND METHOD: Twenty one Thai women with stress urinary incontinence attending the gynecology clinic at King Chulalongkorn Memorial hospital were recruited. Pre operative clinical and urodynamic evaluation were done. They underwent Laparoscopic burch colposuspension between January - December 1998. The cure rate was evaluated by clinical and urodynamic examination. RESULTS: The mean +/- SD of operative time, blood loss and hospital stay were 70 +/- 20 min, 140 +/- 30 ml and 1.6 +/- 0.5 days respectively. The complication rate was 19.1% (Bladder injuries 2 cases, voiding difficulties 1 case and de novo detrusor overactivity 1 case). The objective cure rate at 5 years was 76.2%. CONCLUSION: The authors found that the cure rate was rather low in laparoscopic burch colposuspension. Due to the long operative time, the requirement of complicated instruments and well trained physicians, the authors suggested that this technique should be selected only in cases of women with concomitant gynecologic disease that required lapascopic surgery.

Adult↗

PubMed2005

Changes in brain activity following sacral neuromodulation for urinary retention.

PURPOSE: Sacral nerve stimulation (neuromodulation) can restore bladder sensation and the ability to void in women with urinary retention due to sphincter overactivity (Fowler's syndrome). Modulation of central afferent activity is considered critical to this therapeutic effect but the neural mechanisms are poorly understood. Therefore, we undertook a functional brain imaging study to determine how neuromodulation acts on brain centers involved in the representation and control of bladder function. MATERIALS AND METHODS: Eight patients with Fowler's syndrome and 8 healthy controls underwent brain imaging with positron emission tomography to identify regions of brain activity relating to the perception of bladder fullness and their modulation by sacral nerve stimulation. RESULTS: In healthy controls bladder fullness enhanced activity in brainstem (midbrain) and limbic cortical regions. Women with urinary retention showed no significant brainstem activity but did show enhanced limbic cortical activity when the bladder was full in the absence of neuromodulation. Neuromodulation restored a normal pattern of midbrain activity and decreased cortical activity in this group. CONCLUSIONS: Our study provides novel neuroimaging evidence for the existence of abnormal interaction between brainstem and cortical centers in women with urinary retention. Furthermore, we have been able to show evidence that the therapeutic effect of sacral neuromodulation is achieved through restoration of activity associated with brainstem autoregulation and attenuation of cingulate activity.

Adult↗