Early intermittent self-catheterisation after spinal cord injury

An evaluation has been made of intermittent self-catheterisation (ISC) carried out by 25 paraplegic patients early after injury. The results were compared with those of intermittent catheterisation (IC) done in another 48 paraplegic patients by a catheter team. No significant difference was found regarding the rate of urinary infection or the incidence of urethral trauma. The final outcome of bladder training did not differ significantly between the two groups. Patients on self-catheterisation went home earlier for the weekend. Most patients and their relatives found that self-catheterisation in the early stage was easy to perform and meant a more active participation in bladder training. Early self-catheterisation may help to overcome a nursing staff shortage in a busy acute spinal cord injury ward.     

Intermittent urethral self-catheterisation: long term results (bacteriological evolution, continence, acceptance, complications).

Forty six (9%) out of 520 patients from the years 1976 to 1982 who used intermittent urethral self-catheterisation (IUSC) as the method of bladder drainage at the moment of discharge from the Swiss Paraplegic Centre of Basel were analysed during their rehabilitation period, on discharge, 3, 6 months later and again 5 years later regarding bacteriological changes and urinary tract infections, behaviour of some problem germs such as Proteus, Klebsiella and Pseudomonas, sterile versus clean catheterisation, catheterisation frequency, complications, continence and acceptance of this method. Only 22 patients continue IUSC, 5 have died, 6 use indwelling catheters and 13 are voiding their neurogenic bladder with other methods. Average time on IUSC was 6.6 years (0.5-13 years) in the women's group and 4.6 years (0.5-12 years) in the men's group. Of the remaining 22 patients on IUSC, 23% have sterile urines, 36.5% are infected with E. coli and Enterococci, 4.5% with Staphylococci and the remaining 36% still show the problem germs Pseudomonas (4.5%), Proteus (13.5%) and Klebsiella (18%), but there was a reduction from 19 cases with problem germs in 1983 to 11 cases in 1988. In 1988 5% women and 4% men changed from sterile to clean IUSC (2 out of 11 men using the same catheter for at least 1 week and 2 out of 10 women). The complication rate was astonishingly low during IUSC: being only 4.3% (2 male patients, one with stricture of the urethra and epididymitis, one with autonomous dysreflexia with bladder overdistension). No anti-cholinergic or alpha-stimulating agents were used nor continuous antibiotic-prophylaxis and only in one female patient was a bladder denervation procedure performed. No deterioration of the upper urinary tract was observed. The degree of continence remained stable throughout the follow-up, and the same applies to the acceptance of IUSC. The authors conclude that IUSC can be of great help in neuropathic bladder rehabilitation provided that the patients are properly selected, motivated and well instructed and followed throughout the years.     

Percutaneous annuloplasty in the treatment of discogenic pain: retrospective evaluation of one year follow-up

In this study, we have evaluated clinical results of the discTRODE system, in 15 patients with discogenic pain. All procedures were performed under sterile conditions with fluoroscopic guidance. After identifying the disc space under fluoroscopy, the introducer of the discTRODE was introduced using a tunneled vision. After inserting the introducer; navigable, semi-rigid discTRODE catheter was advanced through the introducer and directed medially and contralaterally along the posterior nuclear-annular interface. The SMK Thermocouple Electrode was placed in the outer-annulus on the contralateral side so as to monitor local tissue temperature. The treatment temperature was manually increased in a step-wise progression from 50 degrees C to 65 degrees C. Patient outcomes were evaluated during follow-up visits at 1, 3, 6 and 12th months post-procedure. Before the procedure and at each visit during the follow-up period, patients completed Visual Analogue Pain Scale (VAS) and Short Form-36 Health Status Questionnaire (SF-36). Annuloplasty was performed without difficulty in all patients, there were no complications associated with disc puncture such as discitis or disc rupture. Symptoms improved in 10 of 15 (66.6 %) of the patients on the SF-36 Physical Function subscale, in 9 of 15 (60 %) on the SF-36 Bodily Pain subscale and in 9 of 15 (60 %) on the VAS scores. 5 of 15 of the patients did not show improvement on any scale. This technique seems to be a reliable method for patients complaining of discogenic pain. However, prospective randomized controlled studies comparing different approaches are needed.     

Incomplete emptying and urinary retention in multiple‐system atrophy: When does it occur and how do we manage it?

Neurogenic urinary retention can be a major cause of morbidity in multiple-system atrophy (MSA). However, the timing of its appearance has not been entirely clear, and neither have the medical and surgical modalities for managing patients. We present the data obtained from our uroneurological assessment and therapeutic interventions at various stages of MSA. We recruited 245 patients with probable MSA. We measured postvoid residuals (PVR) and performed EMG cystometry in all patients. The grand average volume of PVR was 140 mL (range, 0-760) in our patients. The average PVR volume was 71 mL in the first year, increasing to 129 mL in the second year and 170 mL by the fifth year. The percentages of patients with complete urinary retention, acontractile detrusor, and detrusor-sphincter dyssynergia (DSD) also increased. The increase in PVR resulted in a decrease in functional bladder capacity, together with an increase in detrusor overactivity and neurogenic sphincter EMG. Clean intermittent self-catheterization (CISC) was introduced in most patients. Bladder-oriented therapy (cholinergic agents) had a limited value, whereas urethra-oriented therapy benefited patients with DSD (surgery) for up to 2 years, but syncope occurred in a subset of patients (alpha-blockers). MSA patients present with large PVR by the second year of illness, and that large PVR secondarily causes urinary frequency. CISC is the recommended treatment for most patients. Urethra-oriented medication and surgery benefit patients who would have difficulty performing CISC, although careful consideration of the short-term efficacy and potential adverse effects of these alternatives is mandatory.     

PCR in lyme neuroborreliosis: a prospective study

OBJECTIVES: DNA proof is the only widely available direct diagnostic tool in Lyme borreliosis. Sensitive PCR detecting of spirochetal DNA was prepared and a prospective study in neuroborreliosis was performed. MATERIALS AND METHODS: 57 hospitalised patients with active neuroborreliosis and proved CSF antibodies synthesis were examined. Nested-PCR (utilizing three targets) was used for the detection of specific DNA in plasma, CSF and urine. RESULTS: Before treatment 36 positive patients (63.1%) were found in all tested specimens in parallel, 28 patients (49.1%) were positive in urine, 20 in CSF (35.0%) and 16 in plasma 28.0%). Later only urine was tested and the following results were obtained: 17 positive patients (30.0%) immediately after treatment, 8 (14.0%) after 3 months and one patient persisted positivity after 6 months. CONCLUSIONS: The highest sensitivity of PCR was achieved in the acute period of neuroborreliosis - 63.1% in three body fluids comparing with CSF antibody synthesis.     

Does routine screening for benzodiazepines help to diagnose dependence in psychiatric inpatients?

After admission, 899 inpatients of a psychiatric university hospital were routinely screened for benzodiazepines (BDZ) in the urine. BDZ were detected in 134 (15%) patients with various primary diagnoses. Criteria for BDZ abuse or dependence were found in 36 patients. In 35 cases, either intake of BDZ had not been reported in the first psychiatric interview, or such a report had not been documented in the patient's charts. None of these 35 patients was found to have BDZ abuse or dependence. Psychiatric inpatients with BDZ abuse or dependence seem to report their intake of BDZ. These findings suggest that a routine screening for BDZ can hardly help to diagnose dependence within a university hospital setting. Nevertheless, an objective test for intake of BDZ may be useful in special cases.     

缺血性脑血管病患者血浆LCAT活性的初步探讨

本文应用外加底物法测定１０３例缺血性脑血管病病人和３６例健康人的血浆ＬＣＡＴ活性和脂蛋白含量，病人组包括脑动脉硬化症患者４０例，脑血栓形成患者６３例。研究结果表明：ＩＣＶＡ患者血浆ＬＣＡＴ活性下降，脑血栓形成急性期下降尤著；ＬＣＡＴ活性与ＨＤＬ－Ｃ，ＨＤＬ２－Ｃ及ａｐｏＡ－Ｉ呈正相关，与ＬＤＬ－Ｃ／ＨＤＬ－Ｃ呈负相关，其中与ＨＤＬ－Ｃ相关性最强。     

Atrial septal aneurysm: association with cerebrovascular and peripheral embolic events

Patient records in 36 consecutively identified patients with typical echocardiographic findings of atrial septal aneurysm were reviewed. Ten of the 36 (28%) had cerebrovascular events. Of these 10, 5 had completed strokes of definite embolic origin on the basis of clinical, angiographic, and computed tomographic findings; 2 had transient ischemic attacks of probable embolic origin. One of the 36 patients had a definite peripheral vascular embolus. Thus, 6 of 36 consecutively identified patients with atrial septal aneurysm (17%) had definite embolic events and 8 of 36 (22%) had definite or possible embolic events. The cause of the association between atrial septal aneurysm and emboli is unknown. While aneurysm-associated thrombus has been suggested, the high proportion (90%) of patients with interatrial shunting demonstrated by contrast echocardiography in this study suggests paradoxical embolization as a potential cause. Whatever its mechanism, the high prevalence of embolic events in this series strongly supports the premise that atrial septal aneurysm is a cardiac abnormality with embolic potential.     

Long-Term Outcome of West Syndrome: A Study of Adults with a History of Infantile Spasms

Summary: To our knowledge, ours is the first study to evaluate the outcome of infantile spasms (IS) in adult patients. We analyzed 214 children born between 1960 and 1976 who had been followed for 20–35 years or until death at 3 months to 30 years of age. Mortality was 31% (67 of 214 patients). Thirty-six of the surviving patients (24%) had normal (25 patients) or only slightly impaired (11 patients) intelligence as assessed by their educational abilities. Four had academic occupations. Eight were married or living unmarried with a partner. Five had healthy children. At follow-up, the EEGs of the 25 normal persons were either normal or slightly abnormal, demonstrated focal findings in 9 (36%), and had unspecific changes in 1. Focal abnormalities were not more common in patients with less good outcomes (37%). In patients with normal neurological outcomes, IS had been classified as cryptogenic only in 9 of 25 (36%) cases. Therefore, some patients with IS apparently have normal intelligence and socioeconomic status as adults, including patients whose spasms were either symptomatic or associated with focal EEG findings.     

Neurourodynamic evaluation of voiding dysfunction in multiple sclerosis

During a period of 2 1/2 years, 198 patients with definite MS were admitted to our neurological department. 88 were investigated neurourodynamically because of distinct voiding dysfunction. 73 patients showed detrusor hyperreflexia, 14 detrusor hyporeflexia or areflexia and one had normal findings. There was no obvious correlation between the occurrence of the symptoms, irritative and obstructive, and the allocation of the patients into different cystometric groups. The predominant symptom was urge incontinence. More men had been treated or were permanently treated with intravesical catheter, but mean residual urine did not show any sex difference. In 36 patients with detrusor hyperreflexia, dyssynergia was observed and was classified into 3 groups. In the group with clonic sphincter EMG activity during voiding, 5 of the patients had dyssynergia because of flexor spasms transmitted to the sphincter. In patients with dyssynergia characterized by increased sphincter activity throughout detrusor contraction, a large mean residual urine was noted, but dyssynergia did not always prevent acceptable emptying. A low rate of complication in the upper urinary tract was observed. Treatment is discussed.     

The spectrum of central nervous system involvement in Whipple's disease

Background and purpose

To assess the clinical spectrum of central nervous system (CNS) involvement as well as cerebrospinal fluid (CSF) and neuroimaging findings in patients with Whipple's disease (WD) and to analyze the association of neurological symptoms with CSF and imaging findings.

Methods

Neurological involvement was retrospectively analyzed in a series of 36 patients diagnosed with WD at a single center between 1992 and 2019. Findings of 81 comprehensive CSF examinations from 36 patients, including polymerase chain reaction (PCR) tests for Tropheryma whipplei (TW) in CSF from 35 patients, were systematically evaluated. The prevalence of ischemic stroke in patients with WD was compared to a matched control cohort.

Results

Neurological symptoms occurred in 23 of 36 (63.9%) patients, with cognitive, motor, and oculomotor dysfunction being most frequent. TW was detected by PCR in CSF of 13 of 22 (59.1%) patients with and four of 13 (30.8%, p = 0.0496) patients without neurological symptoms. Total CSF protein (p = 0.044) and lactate (p = 0.035) were moderately elevated in WD with neurologic symptoms compared with WD without. No intrathecal immunoglobulin synthesis was observed. Three of 36 (8.3%) patients had hydrocephalus due to aqueductal stenosis. Patients with WD had an unexpectedly high prevalence of ischemic stroke (10/36, 27.7%) compared to matched controls (10/360, 3.2%).

Conclusions

Neurological involvement in patients with WD is common. Detection of TW DNA in CSF is only partly associated with neurological symptoms. Elevated CSF parameters suggest CNS parenchymal infection. Stroke is a hitherto underrecognized manifestation of WD. These findings suggest that mechanisms beyond CNS infection contribute to the spectrum of CNS involvement in WD.     

Water intoxication and syndrome of inappropriate secretion of antidiuretic hormone in schizophrenic patients evaluated by water deprivation and load tests

A study was conducted on 16 schizophrenic patients with compulsive water drinking (CWD) and 10 normal controls, and the relation between serum antidiuretic hormone (ADH) and serum osmolality measured under ordinary conditions of free water intake. A water deprivation test and a water load test were also carried out on 10 schizophrenics with CWD and 10 normal controls. A comparison between the patients and controls showed the following results: the patients showed a significantly high level of serum ADH for their serum osmolality level, and 3 of them were consistent with the syndrome of inappropriate secretion of ADH (SIADH); the urine osmolality after the water deprivation in the patients was relatively low for their serum ADH; inhibition of ADH secretion after the water load was insufficient in the patients; and the water load test proved favorable to water diuresis (106%) in the patients with CWD of less than a 5-year duration, and insufficient diuresis (62.6%) in the patients with CWD of more than a 5-year duration. Two cases of the latter group had SIADH. The dilution and concentration of the urine after the water load were delayed also in the schizophrenic patients without SIADH. These findings suggest a strong possibility that the regulatory mechanism of ADH secretion might be impaired in the schizophrenic patients with CWD.     

Survey of diurnal weight gain and urine volume in chronic schizophrenia

We found diurnal weight gain to be abnormal among 39 chronic schizophrenic patients. The patients were weighed and urine samples obtained weekly for three weeks at 7 a.m. and 4 p.m. We normalized the dirunal weight gain (NDWG) as a percentage by subtracting the 7 a.m. weight from the 4 p.m. weight, multiplying the difference by 100, and then dividing the result by the 7 a.m. weight. NDWG was 2.075 +/- 1.331% for the 38 study patients, .631 +/- .405% for 16 acutely psychotic controls and .511 +/- .351% for 29 normals. Seventy-seven percent of the study patients had abnormal NDWG values and 62% were polyuric. NDWG related to urine volume (n = 39, r = .356, p = .026) with the variability in urine excretion explaining 13% of the variability in NDWG. We discuss factors that may have contributed to our findings.     

Daily psychosocial stressors and cyclic response patterns in urine cortisol and neopterin in a patient with systemic lupus erythematosus

This study investigated the complex biochemical responses to personally meaningful everyday stressors in a patient with systemic lupus erythematosus (SLE). For this purpose, a 52 year-old woman with SLE collected her entire urine for 56 days on a 12-h basis for the determination of cortisol as well as neopterin, a cellular immune parameter. Additionally, using questionnaires, daily notes and interviews, extensive psychosocial and psychological time-series data were collected every 12 h. Cross-correlational analyses of the resulting time-series revealed that stressful incidents were associated with cyclic fluctuations in both urine cortisol and urine neopterin. Specifically, whenever the patient anticipated a moderately stressful incident, urine cortisol initially increased 24 h before the incident and then decreased 12 h before the incident. Moderate stressors not anticipated by the patient were associated with an initial increase 24 h following the incident and then with a decrease after a total of 36 h. Moreover, stressors having to do with the patient's extramarital relationship were followed initially by a decrease in urine neopterin after 36 h and then by an increase after a total of 60 h. Our findings indicate that when investigating the relationship between psychosocial stressors and biochemical activity in SLE, appropriate consideration of the data's dynamic nature may be necessary to avoid flawed conclusions.     

Non-inflatable penile prosthesis for the management of urinary incontinence and sexual disability of patients with spinal cord injury

During the last 5 years non-inflatable penile prostheses were implanted in 37 patients with spinal cord injury. Operation was done to provide adequate stability of the penis in order to hold an external urinary device, to help erectile impotence and to make self-catheterisation easier. A pair of Shirai-type silicone penile implants were inserted into the corpora cavernosa through a dorsal skin incision at the penile base. In 37 patients 33 had excellent results. Extrusion of the prosthesis occurred in two cases due to infection. Removal of the prosthesis was necessary in a patient who had causalgia in the lower extremities. Posterior migration of the prosthesis was noted in a tetraplegic patient who used to turn on his stomach when he changed clothes. Anterior sphincterotomy which was performed during the surgery in one case and after the surgery in another two cases did not affect the prosthesis. Questionnaire survey revealed that 32 (86%) were satisfied with the procedure which provided better condom fitting and easier intermittent catheterisation whereas only 5 (14%) were dissatisfied. The prosthesis improved sexual function in 15 (41%) patients, 18 (48%) patients were unchanged and four (11%) patients were dissatisfied. Penile prosthesis is an effective manoeuvre for the treatment of urinary incontinence and sexual disability of patients with spinal cord injury provided that the special aspects of the spinal cord injury is taken into consideration.     

Axonal Guillain-Barré syndrome: relation to anti-ganglioside antibodies and Campylobacter jejuni infection in Japan

To clarify the relations of the axonal form of Guillain-Barré syndrome (GBS) to anti-ganglioside antibodies and Campylobacter jejuni infection, 86 consecutive Japanese GBS patients were studied. Electrodiagnostic criteria showed acute inflammatory demyelinating polyneuropathy in 36% of the patients and acute motor axonal neuropathy (AMAN) in 38%. Frequent anti-ganglioside antibodies were of the IgG class and against GM1 (40%), GD1a (30%), GalNAc-GD1a (17%), and GD1b (21%). Identified infections were C. jejuni (23%), cytomegalovirus (10%), Mycoplasma pneumoniae (6%), and Epstein-Barr virus (3%). There was a strong association between AMAN and IgG antibodies against GM1, GD1a, GalNAc-GD1a, or GD1b. Almost all the patients with at least one of these antibodies had the AMAN pattern or rapid resolution of conduction slowing/block possibly because of early-reversible changes on the axolemma. C. jejuni infection was frequently associated with AMAN or anti-ganglioside antibodies, but more than half of the patients with AMAN or anti-ganglioside antibodies were C. jejuni-negative. These findings suggest that the three phenomena "axonal dysfunctions (AMAN or early-reversible conduction failure)," "IgG antibodies against GM1, GD1a, GalNAc-GD1a, or GD1b," and "C. jejuni infection" are closely associated but that microorganisms other than C. jejuni frequently trigger an anti-ganglioside response and elicit axonal GBS.     

Dysfunctional urinary voiding in women with functional defecatory disorders

Background While pelvic floor dysfunction may manifest with bladder or bowel symptoms, the relationship between functional defecatory disorders and dysfunctional voiding is unclear. Our hypothesis was that patients with defecatory disorders have generalized pelvic floor dysfunction, manifesting as dysfunctional urinary voiding. Methods Voiding was assessed by a symptom questionnaire, a voiding diary, uroflowmetry, and by measuring the postvoid residual urine volume in this case‐control study of 28 patients with a functional defecatory disorder (36 ± 2 years, mean ± SEM) and 30 healthy women (36 ± 2 years). Key Results Women with a defecatory disorder frequently reported urinary symptoms: urgency (61%), frequency (36%), straining to begin (21%), or finish (50%) voiding, and the sense of incomplete emptying (54%). Fluid intake and output, the minimum voided volume, and the shortest duration between voids measured by voiding diaries were higher (P < 0.05) in patients than in controls. Uroflowmetry revealed abnormalities in seven controls and 22 patients. The risk of abnormal voiding by uroflowmetry was higher in patients (OR 8.0; 95% CI, 2.3–26.9) than in controls. Patients took longer than controls (P < 0.01) to attain the maximum urinary flow rate (12 ± 2 VS 4 ± 0 s) and to empty the bladder (29 ± 4 VS 20 ± 2 s), but the maximum urinary flow rate and postvoid residual volumes were not significantly different. Conclusions & Inferences Symptoms of dysfunctional voiding and uroflowmetric abnormalities occurred more frequently, suggesting of disordered urination, in women with a defecatory disorder than in healthy controls.     

The schizoaffective disorder diagnosis: a conundrum in the clinical setting

The term schizoaffective was introduced to describe the co-occurrence of both psychotic and affective symptoms. Overtime, as the diagnosis schizoaffective disorder was added to diagnostic manuals, significant concerns were raised as to the reliability and clinical utility of the diagnosis. We recruited 134 psychiatrically hospitalized subjects who had received a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder with psychotic features by their treating clinician. The subjects were also diagnosed by trained research personnel with the Structured Clinical Interview of the DSM-IV-TR, employing an explicit time threshold for criterion C of the schizoaffective disorder diagnosis. We found significant differences between the clinical and research diagnoses. Clinicians diagnosed 48 patients (36 %) with schizophrenia, 50 patients (37 %) with schizoaffective disorder and 36 patients (27 %) with psychotic bipolar disorder. In contrast, researchers diagnosed 64 patients (48 %) with schizophrenia, 38 patients (28 %) with schizoaffective disorder and 32 patients (24 %) with psychotic bipolar disorder. This was a statistically significant disagreement between the research and clinical diagnoses (p = 0.003) and indicates that clinicians choose the less severe diagnosis for psychotic patients. We conclude that a more stringent criterion C for the schizoaffective disorder diagnosis will address an implicit bias in clinical practice and will affect the prevalence of the psychotic disorder diagnoses.     

A Study on Recidivism in the Psychiatric Emergency Room

Our goal in this retrospective study was to assess empirical risk factors for repeat visits to the psychiatric emergency room. This information may be useful for targeted prevention and cost-effective service planning. Over a 7-month period, 400 (18%) of 2212 patients were repeat visitors, accounting for 36% of all visits. A diagnosis of a psychotic disorder at the first visit was a risk factor for a repeat visit, especially in young patients. Substance abuse, as suggested by positive urine toxicology, decreased the likelihood of recidivism, but positive toxicology screens in young schizophrenic patients increased the chances of a repeat visit. In a 1-month consecutive sample of 311 patients, unemployment and homelessness were stronger correlates than a clinical diagnosis of schizophrenia. These findings support previous evidence that psychiatric emergency services are often used by underprivileged patients. We suggest that a rational preventive approach to reduce recidivism in psychiatric emergency services may include substance abuse treatment and case management for young schizophrenics and community outreach projects for socially disadvantaged patients. Compliance of recidivist patients poses a difficult task for case managers and community psychiatrists. More studies are needed to assess the efficacy of these interventions.     

Nerve injuries following intramuscular injections: a clinical and neurophysiological study from Northwest India

In developing countries, injections are frequently used to treat common ailments. Intramuscular injections (IMI) may damage peripheral nerves at the site of injection. Our objectives were to study the clinical features, neurophysiological findings, and outcome in patients with nerve injuries (NI) following IMI and to determine the factors affecting prognosis. We conducted a retrospective review of patients with NI following IMI, who were referred to our Neurophysiology Laboratory at Christian Medical College, Ludhiana, India, between January 1990 to December 2003. There were 36 (55%) patients with sciatic nerve palsy, 29 (44%) patients with radial nerve injury, and 1 (1%) patient with posterior femoral cutaneous nerve injury. In 57 (86%) patients, the IMI were given by uncertified medical practitioners. Needle electromyography (EMG) was analyzed in 36 patients (>or=60 days after onset). In 12 (33%) patients, there was EMG evidence of axonal damage with reinnervation, while in the other 24 (67%) patients, there was axonal damage without reinnervation. Only 18 (28%) patients had a good recovery. In conclusion, NI following IMI is a preventable iatrogenic hazard, which carries a poor prognosis.