Lower Urinary Tract Dysfunction in Multiple Sclerosis

Multiple sclerosis is commonly associated with bladder dysfunction, which is frequently reported to be the worst aspect of the disease. Patients may experience bothersome bladder symptoms early in the course, and this should be explored. If necessary, a formal evaluation of the lower urinary tract should be offered. The type of bladder dysfunction may also change with time, which highlights the need for continual follow-up assessments. Anticipated problems are incomplete bladder emptying and disorders with urine storage, which may occur simultaneously. This may lead to symptoms of overactive bladder and recurrent urinary tract infections. Conservative measures for management should be used initially while other sinister pathology is excluded. Newer treatments such as botulinum toxin A and neural stimulation techniques are replacing more invasive surgical procedures. Treatment approaches have been described and should be offered by teams who are familiar with patients having uro-neurological complaints.     

Forget about forgetting: structural barriers and severe non-adherence to antiretroviral therapy

HIV infection is now clinically manageable with antiretroviral therapy (ART). However, a significant number of people with HIV do not benefit from ART because of non-adherence. This study examined the use of adherence strategies and barriers to adherence among persons at substantial risk for developing resistant virus (less than 75% adherent). People living with HIV (n?=?556) who were less than 95% adherent to ART completed computerized interviews, were screened for active drug use, provided medical records for HIV viral load, and completed unannounced pill counts to monitor ART adherence and an assessment of adherence barriers. Based on pill counts, participants were defined as severely non-adherent (≤75% medications taken) and moderately non-adherent (>75% and <95% adherent). Results showed a broad array of memory devices were used to no avail across non-adherence groups. Individuals who were severely non-adherent were significantly more likely to attribute missing medications due to substance use and structural barriers, including running out of medications, inability to get to pharmacy, and inability to afford medications. Results suggest that interventions focused on memory lapses will be insufficient and should rather concentrate on substance use treatment and providing case management to resolve structural barriers to adherence.     

Characterization of end-of-life electroencephalographic surges in critically ill patients

Neuromonitoring devices to assess level of sedation are now used commonly in many hospital settings. The authors previously reported that electroencephalicgraphic (EEG) spikes frequently occurred after the time of death in patients being neuromonitored at the time of cessation of circulation. In addition to the initial report, end-of-life electrical surges (ELES) have been subsequently documented in animal and human studies by other investigators. The frequency, character, intensity, and significance of ELES are unknown. Some have proposed that patients should not be declared dead for purposes of organ donation prior to the occurrence of an ELES. If clinical practice were altered to await the presence of an ELES, there could be detrimental consequences to donated organs and their recipients. To better characterize ELES, the authors retrospectively assessed the frequency and nature of ELES in serial patients. To better document ELES, they collected neuromonitoring, demographic, and clinical data on consecutive patients who expired while being actively monitored as part of their standard palliative care. These data were retrospectively collected when available as a convenience sample. The authors assessed 35 patients of which 7 were clinically confirmed as brain dead. None of the brain-dead patients displayed an ELES. Thirteen of the 28 remaining patients (46.4%) exhibited an ELES. The ELES observed were demonstrated to have high frequency EEG signal. The mean peak amplitude of ELES as measured by Patient State Index^TM (PSI) was 58.5?±?25.7. In this preliminary assessment, the authors found that ELES are common in critically ill patients who succumb. The exact cause and significance of ELES remain unknown; further study is warranted.     

Posttraumatic Stress Disorder and One‐Year Outcome in Methadone Maintenance Treatment

Background: Although opiate use may be associated with posttraumatic stress disorder (PTSD), it is not clear whether PTSD is associated with retention in methadone maintenance. Objectives: To evaluate among those receiving methadone maintenance at an urban methadone maintenance clinic the frequency of life‐time traumatic experiences, the predictors and prevalence of current PTSD, and whether PTSD affects retention at 1 year. Methods: Eighty‐nine people participated in the study. The Post Traumatic Diagnostic Scale was used to determine the prevalence of PTSD. The Life Stressor Checklist Revised was used to evaluate trauma history. Logistic regression analyses examined associations between demographic characteristics, substance use, trauma‐related variables, and PTSD. Similar logistic regression analyses were used to examine retention in methadone maintenance at 1 year. Results: The mean number of reported lifetime stressful events was 8.0 (SD = 3.7). Twenty‐seven percent were diagnosed with PTSD. Nearly 92% of those with PTSD had co‐occurring depressive symptoms. Female gender (adjusted odds ratio [AOR][95% CI]; 3.89 [1.07–14.01]), number of traumatic events (AOR [95% CI]; 1.34 [1.13–1.61]), and less education (AOR [95% CI]; 4.13 [1.14–14.98]) were significantly associated with PTSD. Those with a toxicology positive screen were 80% less likely to remaine in methadone maintenance at 1 year (OR [95% CI]; 0.20 [0.07–0.52]). PTSD diagnosis was not significantly associated with treatment retention at 1 year (OR [95% CI]; 0.61 [0.23–1.64]). Conclusions and Scientific Significance: Future studies are needed to determine if treatment of PTSD that is integrated into methadone maintenance programs may impact continued substance abuse use and thereby improve retention in care. (Am J Addict 2012;21:524–530)