Pseudomonas aeruginosa colonization in patients with spinal cord injuries.

The prevalence of Pseudomonas aeruginosa colonization of patients with spinal cord injury was studied annually from 1976 to 1980. The urethra, perineum, rectum, drainage bag, and urine of patients on the spinal cord injury service were cultured. A total of 224 men and 32 women were studied. Most patients were managed with an external urinary collection system or padding, with or without intermittent catheterization. P. aeruginosa was cultured from one or more body sites (urethra, perineum, or rectum) in 65% of men and 18% of women. Drainage bags on the beds were frequently colonized with P. aeruginosa (73%). Significant bacteriuria with P. aeruginosa was present in 19% of the men and 13% of the women. P. aeruginosa colonization of body sites in men was closely associated with the use of an external urinary collection system. Significantly greater urethral and perineal colonization was found in men using an external urinary collection system. P. aeruginosa serotype 11 was the predominant serotype for the first 3 years, and the number of patients colonized with serotype 11 increased with length of hospital stay. The prevalence of serotype 11 significantly decreased in the last 2 years. The antibiotic susceptibility of the strains of P. aeruginosa isolated from these patients did not change in the 5 years, except that there was increasing susceptibility to carbenicillin in later years. This increasing susceptibility to carbenicillin was a reflection of a decreased prevalence of serotype 11 in these patients, since serotype 11 was more resistant than other serotypes to carbenicillin.     

Incidence and risk factors associated with urinary tract infection in diabetic patients with and without asymptomatic bacteriuria

In order to compare the incidence of symptomatic urinary tract infection (UTI) in diabetic patients with and without asymptomatic bacteriuria (ASB), and to identify other risk factors for these infections, 289 females and 168 males were studied over a 12-month period. Symptomatic UTI occurred in 69.2% of patients with ASB (67.6% female and 76.5% male) versus 9.8% without ASB (14.9% female and 2.6% male). ASB and urinary incontinence were associated with symptomatic UTI in both women and men. Other risk factors included previous antimicrobial treatment and macrovascular complications in women and obesity and prostatic syndrome in men. The presence of ASB was found to be the major risk factor for developing symptomatic urinary tract infection. Further prospective randomized clinical trials of diabetic patients with risk factors for UTI who are receiving or not receiving treatment may be considered.     

The ameliorating effect of dantrolene on the morphology of urinary bladder in spinal cord injured rats

In animal models of spinal cord injury (SCI), the urinary bladder can undergo significant structural and physiological alterations. Dantrolene has been shown to be neuroprotective by reducing neuronal apoptosis after SCI. Furthermore, in addition to its anti-inflammatory and antioxidant properties, it appears to have a beneficial action on voiding, once this drug acts on the external urethral sphincter relaxation. In the present study, we investigated the effects of dantrolene on urinary bladder injury that follows experimental SCI. Forty-six male Wistar rats were laminectomized at T13, and a compressive trauma was performed to induce SCI. After euthanasia, the urinary bladder was removed for gross and histological evaluation. Traumatized animals showed urinary retention with severe hemorrhagic cystitis. Injured animals treated with dantrolene had less bladder hemorrhage and inflammatory infiltrate than those treated with placebo (p<0.05). Our results demonstrate that dantrolene may protect against urinary bladder lesions that follow SCI. Treating spinal cord-injured patients with this agent may be a promising additional therapeutic strategy to alleviate the accompanying inflammatory process. The results of the current study show that dantrolene has protective effects on spinal cord contusion-induced urinary bladder injury. The impaired integrity of bladder morphology was ameliorated by dantrolene treatment.     

Urinary incontinence in older people in the community: a neglected problem?

BACKGROUND: The prevalence and impact of urinary incontinence has been investigated much less in older men than in older women. It is suggested that those who perceive that their daily lives are affected should have priority for services. However, many people do not seek medical help, even though they may be severely affected. AIM: To investigate unmet need in relation to the prevalence and impact on everyday life of urinary incontinence in men and women over the age of 65 years. DESIGN OF STUDY: Cross-sectional survey to measure prevalence of urinary incontinence, the impact on people's lives, use of protection, and health services. SETTING: Stratified random sample of 2000 community-living elderly (equal numbers of men and women, aged 65 to 74 years and over 75 years) in 11 general practices in a British city. RESULTS: The response rate was 79%. The overall prevalence of incontinence in the previous month was 31% for women and 23% for men. Women generally had more severe frequency of incontinence and a greater degree of wetness than men. Protection use was greater in women than in men. Only 40% of men and 45% of women with incontinence had accessed health services. Significant predictors of the use of health services were: incontinence reported as a problem, increased frequency of incontinence, and greater degree of wetness. About one-third of people who leaked with severe frequency or who reported that it was a problem had not accessed NHS services for incontinence. CONCLUSIONS: Urinary incontinence is a common problem for older men and women living in the community and can have a deleterious effect on their lives. There is the opportunity to improve the lives of many older people with urinary incontinence, probably by a combination of increased public, patient, and professional awareness that should lead to earlier presentation and initiation of effective care.     

Rules for identifying patients at increased risk for candidal infections in the surgical intensive care unit: approach to developing practical criteria for systematic use in antifungal prophylaxis trials.

The high rates of invasive candidiasis among intensive care unit (ICU) patients suggest that antifungal prophylaxis might be of value, but rules identifying patients who would best benefit are not established. Based on a retrospective study of 327 patients who stayed in a surgical ICU for > or = 4 days and had an 11.0% rate of invasive candidiasis, we sought to identify useful predictive rules. As prior work suggests that prompt initiation of prophylaxis is of value, we required our rules to be based on patient data routinely available during the week prior to ICU admission through the third day of the ICU stay. Patients with any combination of diabetes mellitus, new onset hemodialysis, use of total parenteral nutrition, or receipt of broad-spectrum antibiotics had an invasive candidiasis rate of 16.6% versus a 5.1% rate for patients lacking these characteristics (P = 0.001). Fifty-two percent of patients staying > or = 4 days in the ICU met this rule and the rule captured 78% of the patients who eventually developed invasive candidiasis. Risk-stratified antifungal prophylaxis in the ICU is possible. Validation of these results in other types of ICU is now needed.     

Semen retrieval by penile vibratory stimulation in men with spinal cord injury.

Traumatic spinal cord injury resulting from car accidents, falls, violence or sport-related activities is a common occurrence throughout the world. Spinal cord injuries occur most often to young men in their parenting years. Among the medical challenges facing many of these men is the inability to ejaculate via sexual intercourse. To achieve biological fatherhood, their semen may be retrieved by methods of assisted ejaculation. This paper discusses the use of penile vibratory stimulation in men with spinal cord injury, and includes the topics: patient selection and management; proper placement and timing of stimulation; appropriate use of low-amplitude, high-amplitude or dual vibrators; and factors influencing ejaculatory success rate. Also summarized are recent data on semen quality in men with spinal cord injury. When performed properly, penile vibratory stimulation is a safe and easy method of obtaining semen from anejaculatory men with spinal cord injury. Semen quality is better when obtained by penile vibratory stimulation compared with electroejaculation, an alternative method of semen retrieval. For these reasons, and because of the low investment of time and money, it is recommended that penile vibratory stimulation be used as the first line of treatment for anejaculation in men with spinal cord injury.     

Circulating Candida-specific anti-mannan antibodies precede invasive candidiasis in patients undergoing myelo-ablative chemotherapy

The kinetics of circulating Candida mannan and anti-mannan antibodies were studied in consecutive plasma samples, obtained upon hospital admission, of 21 patients with microbiologically proven invasive candidiasis and 30 control patients who underwent myelo-ablative chemotherapy. The detection of Candida anti-mannan antibodies preceded the diagnosis of invasive candidiasis in infected patients, and the antibodies were detected significantly more often in patients who had experienced multiple episodes of neutropenia than in the control group (OR 8.9, 95% CI  5.6–14.3; p <0.05). Mannan was predominantly detected in patients who developed invasive candidiasis during their first episode of neutropenia (OR 3.7, 95% CI  1.4–9.7; p <0.05). This observation suggests that patients with multiple episodes of neutropenia have been previously exposed to Candida and that the presence of anti-mannan antibodies in these patients might be associated with an increased risk of developing clinically manifest invasive candidiasis.     

The reported prevalence of urinary symptoms in women in one rural general practice.

In May 1989 a questionnaire to determine the prevalence of urinary symptoms and vaginal discharge in the community was sent to all women patients born before May 1962 who had been registered with one rural practice for the previous two years. The response rate was 97%. The patients' clinical records were used to validate the replies of those who claimed to have consulted the doctor with these symptoms together with a sample of those who claimed not to have consulted. The reported prevalence of dysuria among the women over the previous two years was 27% and the prevalence of frequency was 34%. However, only 8% of women had received treatment for vaginal infections and 15% treatment for urinary symptoms (10% had confirmed bacteruria). Thirty four per cent of women said they would treat themselves prior to consulting a doctor and 17% would buy proprietary medicines. When asked how long they would wait between the onset of symptoms and seeking medical advice the responses ranged from one to 20 days, with 36% of women reporting that they would wait five days or longer before consulting. Fifty eight per cent of the women patients did not believe that urinary tract infections could have serious consequences and this figure increased to 76% among women who had consulted previously for a urinary tract infection. Patients with recurrent urinary symptoms did not consult any earlier than other women or treat themselves any less often. It can be concluded that there is a need for increased patient education in this area.     

Spinal Fluid Abnormalities in Patients with Chronic Fatigue Syndrome

Arguments exist as to the cause of chronic fatigue syndrome (CFS). Some think that it is an example of symptom amplification indicative of functional or psychogenic illness, while our group thinks that some CFS patients may have brain dysfunction. To further pursue our encephalopathy hypothesis, we did spinal taps on 31 women and 13 men fulfilling the 1994 case definition for CFS and on 8 women and 5 men serving as healthy controls. Our outcome measures were white blood cell count, protein concentration in spinal fluid, and cytokines detectable in spinal fluid. We found that significantly more CFS patients had elevations in either protein levels or number of cells than healthy controls (30 versus 0%), and 13 CFS patients had protein levels and cell numbers that were higher than laboratory norms; patients with abnormal fluid had a lower rate of having comorbid depression than those with normal fluid. In addition, of the 11 cytokines detectable in spinal fluid, (i) levels of granulocyte-macrophage colony-stimulating factor were lower in patients than controls, (ii) levels of interleukin-8 (IL-8) were higher in patients with sudden, influenza-like onset than in patients with gradual onset or in controls, and (iii) IL-10 levels were higher in the patients with abnormal spinal fluids than in those with normal fluid or controls. The results support two hypotheses: that some CFS patients have a neurological abnormality that may contribute to the clinical picture of the illness and that immune dysregulation within the central nervous system may be involved in this process.     

Spinal fluid abnormalities in patients with chronic fatigue syndrome

Arguments exist as to the cause of chronic fatigue syndrome (CFS). Some think that it is an example of symptom amplification indicative of functional or psychogenic illness, while our group thinks that some CFS patients may have brain dysfunction. To further pursue our encephalopathy hypothesis, we did spinal taps on 31 women and 13 men fulfilling the 1994 case definition for CFS and on 8 women and 5 men serving as healthy controls. Our outcome measures were white blood cell count, protein concentration in spinal fluid, and cytokines detectable in spinal fluid. We found that significantly more CFS patients had elevations in either protein levels or number of cells than healthy controls (30 versus 0%), and 13 CFS patients had protein levels and cell numbers that were higher than laboratory norms; patients with abnormal fluid had a lower rate of having comorbid depression than those with normal fluid. In addition, of the 11 cytokines detectable in spinal fluid, (i) levels of granulocyte-macrophage colony-stimulating factor were lower in patients than controls, (ii) levels of interleukin-8 (IL-8) were higher in patients with sudden, influenza-like onset than in patients with gradual onset or in controls, and (iii) IL-10 levels were higher in the patients with abnormal spinal fluids than in those with normal fluid or controls. The results support two hypotheses: that some CFS patients have a neurological abnormality that may contribute to the clinical picture of the illness and that immune dysregulation within the central nervous system may be involved in this process.     

PCR-Restriction Enzyme Analysis for Detection of Candida DNA in Blood from Febrile Patients with Hematological Malignancies

Blood samples were drawn daily from 72 patients who had hematological malignancies, neutropenia, and fever and who had failed to respond to broad-spectrum antibiotics. Each sample was used for conventional fungal blood cultures and for detection and identification of Candida DNA by a PCR method with subsequent restriction enzyme analysis (REA) recently developed in our laboratory. The PCR method was able to detect five CFU of Candida spp. per ml of blood, and subsequent REA of the amplicons allowed the identification of the Candida species most commonly implicated in cases of candidiasis. Thirty-one patients were PCR-REA positive, and four of these patients were also culture positive. The ultimate diagnosis for 13 of these patients and 1 patient who was PCR-REA negative was disseminated candidiasis (confirmed by clinical data, multiple cultures, histology, autopsy, and/or ultrasonographic evidence of hepatosplenic candidiasis). The molecular method is significantly more sensitive than conventional fungal blood cultures and has a high negative predictive value (97.5%) for the development of disseminated candidiasis in neutropenic patients.     

Sex-based differences in early mortality after myocardial infarction. National Registry of Myocardial Infarction 2 Participants.

BACKGROUND: There is conflicting information about whether short-term mortality after myocardial infarction is higher among women than among men after adjustment for age and other prognostic factors. We hypothesized that younger, but not older, women have higher mortality rates during hospitalization than their male peers. METHODS: We analyzed data on 384,878 patients (155,565 women and 229,313 men) who were 30 to 89 years of age and who had been enrolled in the National Registry of Myocardial Infarction 2 between June 1994 and January 1998. Patients who had been transferred from or to other hospitals were excluded. RESULTS: The overall mortality rate during hospitalization was 16.7 percent among the women and 11.5 percent among the men. Sex-based differences in the rates varied according to age. Among patients less than 50 years of age, the mortality rate for the women was more than twice that for the men. The difference in the rates decreased with increasing age and was no longer significant after the age of 74 (P< 0.001 for the interaction between sex and age). Logistic-regression analysis showed that the odds of death were 11.1 percent greater for women than for men with every five-year decrease in age (95 percent confidence interval, 10.1 to 12.1 percent). Differences in medical history, the clinical severity of the infarction, and early management accounted for only about one third of the difference in the risk. After adjustment for these factors, women still had a higher risk of death for every five years of decreasing age (increase in the odds of death, 7.0 percent; 95 percent confidence interval, 5.9 to 8.1 percent). CONCLUSIONS: After myocardial infarction, younger women, but not older women, have higher rates of death during hospitalization than men of the same age. The younger the age of the patients, the higher the risk of death among women relative to men. Younger women with myocardial infarction represent a high-risk group deserving of special study.     

Bone and cartilage turnover markers, bone mineral density, and radiographic damage in men with ankylosing spondylitis

PURPOSE: To determine the levels of bone and cartilage turnover markers in men with ankylosing spondylitis (AS) and to investigate their associations with disease activity, bone mineral density, and radiographic damage of the spine. PATIENTS AND METHODS: This cross-sectional study enrolled 35 men with newly diagnosed AS. The bone mineral densities (BMD) of their lumbar spines and proximal femurs, Bath AS Disease Activity Index (BASDAI), and Bath AS Radiographic Index (BASRI) were evaluated. Urinary C-terminal telopeptide fragments of type I collagen (CTX-I) and type II collagen (CTX-II) levels were determined by enzyme-linked immunosorbent assay, and serum levels of bone-specific alkaline phosphatase (BALP) and osteocalcin were determined by an enzyme immunoassay. Levels of biochemical markers were compared with those of 70 age-matched healthy men. RESULTS: Patients with AS had significantly higher mean urinary CTX-I and CTX-II levels than control subjects (p<0.05). Elevated urinary CTX-I levels correlated well with BASDAI, femoral BMD, and femoral T score (p<0.05), and elevated urinary CTX-II levels correlated well with spinal BASRI (p<0.05) in patients with AS. Mean serum BALP and osteocalcin levels did not differ between patients and controls and did not show any significant correlations with BMD, BASDAI, or BASRI in men with AS. CONCLUSIONS: Elevated CTX-I reflects disease activity and loss of femoral BMD while elevated CTX-II levels correlate well with radiographic damage of the spine, suggesting the usefulness of these markers for monitoring disease activity, loss of BMD, and radiographic damage in men with AS.     

Association between type a behavior pattern and coronary artery spasm in japanese patients

The relations between the Jenkins Activity Survey (JAS) Type A score and coronary atherosclerosis and spasm were examined in 192 patients (115 men and 77 women) undergoing coronary angiography. Thirty-nine men (34%) and 12 women (16%) had significant (>or=75%) coronary stenosis. In 97 patients (54 men and 43 women) with no significant coronary stenosis, a coronary spasm provocation test by 0.2 to 0.4 mg of ergometrine was performed, by which a significant focal spasm (>or=75% reduction of luminal diameter) was induced in 22 men (40%) and 5 women (12%). Men who showed a significant focal spasm had a higher Type A score than men who showed no such spasm (1.9 +/- 8.4 vs. -2.4 x 8.3, p < 0.05). Discriminant analysis in male patients revealed that the induction of coronary spasm can be predicted by the JAS Type A score and smoking habit (p = 0.04). No such association was found for female patients. These results suggest that the Type A behavior pattern as assessed by the JAS may be associated with coronary spasm in Japanese men without significant coronary stenosis.     

Quantitative urine cultures do not reliably detect renal candidiasis in rabbits.

The significance of quantitative urine cultures in patients at risk for hematogenous disseminated candidiasis is controversial. While various concentrations of Candida spp. in urine have been suggested as critical cutoff points in the diagnosis of renal candidiasis, other investigators consider quantitative cultures less critical in diagnosing upper tract infections. To determine the significance of quantitative urine cultures in renal candidiasis, we studied serial quantitative urinary cultures of Candida albicans in a rabbit model of hematogenous infection. Of 197 urine samples from 34 infected animals, 144 were culture positive, with a sensitivity of 73.1% for urine cultures and a lower limit of detection of 10 CFU/ml. The yield of urine cultures varied according to severity and duration of infection. The mean renal and urinary concentrations of C. albicans from rabbits with subacute candidiasis differed significantly from those from rabbits with acute candidiasis (P = 0.013 and P < or = 0.001, respectively). During the first 4 days of subacute renal candidiasis, more than one-half of all urine cultures were negative for C. albicans. Only 12 (8.1%) of 148 urine cultures in animals with subacute renal candidiasis had concentrations of > 10(3) CFU/ml, 2.7% had concentrations of > 10(4) CFU/ml, and none were > or = 10(5) CFU/ml. By comparison, all urine cultures from the animals with lethal acute renal candidiasis had higher concentrations of C. albicans and were positive throughout the course of infection. Urinary concentrations of C. albicans were not predictive of the amount of Candida in the kidney (r < or = 0.49) and did not correlate with survival (r = 0.0232). However, the renal concentration of C. albicans (in CFU/gram) inversely correlated with the duration of survival (in days) of rabbits with renal candidiasis (r = 0.76; P < 0.001). These findings indicate that a negative urine culture in rabbits does not preclude the presence of renal candidiasis. The interpretation of a urine culture positive at any concentration, on the other hand, must involve an analysis of the risk factors for renal candidiasis, for any urinary concentration of C. albicans may reflect kidney infection.     

Plasma thymic hormone activity in patients with chronic mucocutaneous candidiasis

To further characterize the immunological abnormalities in patients with chronic mucocutaneous candidiasis, the thymic hormone activity in their plasma was measured. Of the sixteen patients in the study, seven had chronic diffuse candidiasis, five had candidiasis with endocrinopathies and four had candidiasis with thymoma. Only one patient, an anergic child with chronic diffuse candidiasis had severe deficiency of plasma thymic hormone activity. Two patients, a woman with candidiasis and multiple endocrinopathies and an elderly man with metastatic epithelial thymoma had supranormal values.

These studies indicate that the immunological deficit in most patients with these forms of chronic mucocutaneous candidiasis is not due to deficiency of a thymic inductive activity and suggest that an intrinsic defect exists in the maturation of antigen-responsive lymphoid cells.

     

Early decrease in surface expression of HLA-DQ predicts the development of infection in trauma patients

The behaviour of human leucocyte antigen-DR (HLA-DR) following injury has been extensively studied. However, the behaviour of other class II antigens following trauma has not been characterized as well, despite evidence that HLA-DQ genotype influences the response to several bacterial antigens. Our study attempts to characterize and analyse the behaviour of HLA-DQ after trauma in patients with and without infection. Twenty-five patients were studied following major injury. Fifteen of the 25 patients developed infection (men = 11, women = 4); 10 patients developed no infection (men = 9, women = 1). The mean age was 34 +/- 12 years for patients with no infection and 52 +/- 20 years for those with infection. Monocyte HLA-DQ surface expression was determined using FITC-labelled antibodies and flow cytometry. Expression was compared with a control population of 11 healthy volunteers. The percentage of monocytes expressing HLA-DQ following trauma was reduced in patients with infection and in those without infection, but returned to normal (days 8-14) only in those patients who did not develop infection. Monocyte HLA-DQ mean channel fluorescence was reduced on day 1, but quickly returned to normal in those patients who subsequently developed infection. Stimulated with lipopolysaccharide, the initial samples of 13 patients who developed infection showed that surface expression on these monocytes could be elevated into the normal range. We conclude that HLA-DQ is an additional early marker of outcome that may not function merely as an immune suppressor. The maintained ability of HLA-DQ to present self-antigens may be important in the initial stages of the host response to injury.     

Analysis of the risk factors regarding anterior cruciate ligament reconstruction using multiple-looped semitendinosus tendon

The purpose of this study was to investigate the risk factors regarding anterior cruciate ligament (ACL) reconstruction using autogenous semitendinosus tendon by subjective evaluation of the patients. We studied 63 patients who had been followed for 18 months or longer after surgery. They comprised 31 men and 32 women aged 15-45 (mean, 25.5) years. The patients were divided into two groups by subjective scores. Subjective clinical evaluation was performed using 100 mm visual analogue scale (VAS). In the high score group (group H), the VAS score was 80 mm or higher, and in the low score group (group L), the score was less than 80 mm. Forty three patients were in group H and 20 patients were in group L. The parameters examined were age, gender, sports activity level, preoperative period, complicated meniscus injury, articular cartilage status, graft tendon size, joint stability, and knee extension muscle strength. There were 26 men and 17 women in group H, and 5 men and 15 women in group L. There were significantly more women in group L (p<0.01). The mean preoperative period after injury was 23+/-38 months in group H, and was 52+/-67 months in group L (p<0.05). The average side-to-side differences in anterior laxity were 1.3+/-1.0 mm in group H and 2.2+/-1.6 mm in group L (p<0.01). There were no significant differences in other parameters between the two groups. In this study the risk factors for poor subjective outcome following hamstring ACL surgery was female gender and prolonged delay from injury to operation.     

Sexuality after spinal cord injury: A critical review

The literature on sexuality after spinal cord injury was reviewed. Four major areas were examined: the sexual response cycle, reproductive functioning, sexual behavior and adjustment, and sexual counseling and rehabilitation. Early research focused almost exclusively on the physiology of sexual functioning after spinal injury. There is now an increasing body of information about the psychosocial aspects of sexual adjustment. Methodological problems and areas for future research were critically discussed. Where information was available, emphasis was given to the differences between men and women after spinal cord injury.