Sexual disorders post-stroke: Description of a cohort of patients followed in rehabilitation

INTRODUCTION

The impairments resulting from a stroke can be multiple, including urinary and/or sexual dysfunctions. This acquired brain injury disrupts neurological control of sexual responses.

MAIN OBJECTIVE

to describe sexual disorders, after a first episode of stroke, in a population followed in a physical medicine and rehabilitation (PMR) center.

SECONDARY OBJECTIVES

to gather patients' expectations and PMR physicians' opinions on this subject.

METHOD

Observational, retrospective study in two PRM centers. Post-stroke sexuality was assessed using two validated questionnaires [for men: International Index of Erectile Function 15 (IIEF15) and for women: Female Sexual function Index (FSFI)]. Patients were asked 3 questions to approximate their expectations, and PRM physicians were asked 2 questions for their opinions.

RESULTS

Twenty-four subjects included (17 men/7 women). Thirteen had no post-stroke sexuality. Erectile function was analysable in 4 subjects, 3 of whom had moderate to severe erectile dysfunction. In women, female sexual dysfunction concerned 6/7 women, including lubrication. Ninety-six percent of subjects had never discussed sexuality with their PRM physician. Only 33% would have liked information on this subject. Our PRM physicians rarely discuss post-stroke sexual disability.

CONCLUSION

Post-stroke sexual disorders occur in both sexes. All areas of sexuality may be affected. A large-scale, prospective, controlled, multicenter study is needed to establish stroke as the direct neurological cause of sexual impairment.

[Is there any obstruction other than prostatic obstruction in Idiopathic Parkinson's Disease?]

OBJECTIVE

To highlight the existence of pseudo-dyssynergia in Idiopathic Parkinson's Disease (IPD) constituting a functional bladder outlet obstruction.

MATERIALS AND METHODS

A retrospective study was conducted by including men with a confirmed diagnose of IPD who participated in the SIROCCO rehabilitation program. Patients included clinically exhibited overactive bladder and voiding dysfunction without prostatic hypertrophy ultrasounded. They have been clinically assessed by the Urinary Symptoms Profile (USP) urinary symptom score. Bladder outlet obstruction was assessed by the pressure-flow study. Urodynamic obstruction has been quantified by the bladder obstruction index which depends on detrusor pressure at maximum flow rate and maximum flow rate. It has been defined by a BOOI>40.

RESULTS

The pressure-flow profile was analyzed in 5 patients who met the inclusion criteria. In this group of 5 patients with IPD, the diagnosis was made on average 10.6 years (7-14) before the pressure-flow studies were performed. Our results objectified 4 patients obstructive among 5 and one equivocal patient. A striated pseudo-dyssynergia was found in the 3 obstructive patients and associated with a smooth pseudodyssynergia in one patient.

CONCLUSION

We have observed, in this short series, a pseudo-dyssynergia by subjects suffering from IPD.

LEVEL OF EVIDENCE

3.

Dartos reflex as autonomic assessment in persons with spinal cord injury

Study design

Prospective clinical series.

Objectives

The dartos reflex (DR) produces unilateral elevation of the testis with vermicular contraction of the scrotal skin and penile retraction. It is a somato-autonomic reflex that depends on the T11-L2 sympathetic segment. Its presence was analysed in men with various levels and severities of spinal cord injury (SCI).

Setting

France.

Methods

Male patients with SCI undergoing urodynamic or sexual assessment were included. DR of the scrotum and penis were systematically assessed in addition to the usual neurological examination that included assessment of the autonomic system, cremaster, and sacral reflexes. The DR was evoked by applying a small ice pack on the scrotum, separately to each side.

Results

Forty-six patients were assessed. DRs were always present when the T11-L2 segment was intact above the lesion (low paraplegia below L2) or below the lesion in an upper motor neuron (UMN) syndrome (spastic paraplegia above T10). They were more pronounced in the case of UMN syndrome. In the case of lower motor neuron (LMN) syndrome that included the T11-L2 segment, DRs disappeared in all but one patient. Patients with a LMN lesion were more prone to retrograde or absent ejaculation, loss of psychogenic erection, and open bladder neck.

Conclusions

The DR is a valuable test for the assessment of the integrity and excitability of the T11-L2 spinal segment. It is easy to perform and is predictive of some aspects of sexual and bladder neck function in men. DR should be considered as an addition to the autonomic standards.

Prediction of sexual function following spinal cord injury: a case series

INTRODUCTION

Spinal Cord Injury (SCI) affects sexual response based on the level and degree of completeness of injury. By using the International Standards for the Neurologic Classification of SCI in conjunction with lumbo-sacral reflexes these effects can be predicted. The International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) document the impact of SCI on sexual responses including psychogenic and reflex arousal (erection or lubrication), orgasm, ejaculation, and sensation of menses. Responses are described based upon a 0 to 2 scale with 0 being absent, 1 altered, and 2 normal response. Additionally, the lesion is described as supraconal, conal or infraconal.

CASE PRESENTATION

We present 4 representative cases of the impact of SCI on sexual responses and course of treatment. Case 1 describes a complete supraconal lesion above T6 with upper motor neuron syndrome. Case 2 describes a supraconal complete lesion including the T11-L2 segment. Case 3 describes an infraconal (cauda equina) lesion with lower motor neuron syndrome. Case 4 is theoretical and describes a supraconal lesion above T6 with upper motor neuron syndrome, partial sensation in T11-L2 dermatomes, and other medical comorbidities.

DISCUSSION

Neurologic examination combined with reflex testing allows prediction of sexual responses after SCI. It would be useful for version 2.0 of the ISAFSCI to assist clinicians in determining the anticipated changes, whether their patients are functioning as anticipated sexually after SCI or whether other concerns also require treatment.

Ejaculation and sperm characteristics in men with cauda equina and conus medullaris syndromes

STUDY DESIGN

Retrospective.

OBJECTIVES

The objective of the study was to describe the type of ejaculation in patients with cauda equina (CE) and conus medullaris (CM) lesions, and to analyse sperm quality.

SETTING

France.

METHODS

One hundred sixty-six patients with CE and CM lesions were included. Diagnosis was based on clinical (no motor responses, sensation or sacral reflexes) and urodynamic assessments (no detrusor activity). Vibromassage (VM) was used to induce ejaculation according to the recommendations for patients with spinal cord injury. If ejaculation did not occur, oral midodrine was administered in progressive doses. Retrograde ejaculation was systematically sought. Sperm parameters were analysed according to World Health Organisation recommendations (2010).

RESULTS

Eighty-nine patients were included. Eleven ejaculated on the first VM trial (four anterograde (AE), six retrograde (RE) and one antero-retrograde (ARE)). Five patients continued trials of VM alone, two of whom ejaculated following a mean 1.9 trials (one RE, one ARE). Twenty-six patients underwent trials of VM+ midodrine, 18 of whom ejaculated following a mean 4.4 trials with a mean dose of 22.5 g of midodrine (2 AE, 13 RE and 5 ARE). Fifty-three ejaculates from 26 patients were analysed. Sperm concentration was low in 90.6% of samples; total necrospermia was found in 65% and asthenospermia in 95% of samples.

CONCLUSION

Ejaculation is difficult to induce using VM in patients with CE and CM lesions, and requires high doses of midodrine. Sperm counts were generally low, and asthenospermia and necrospermia were found in the majority of specimens. Cryopreservation of sperm should be systematic in case of medically assisted procreation.

[Assessment of severity of neurogenic bowel dysfunction in chronic patients with a simple 1-item questionnaire (PGI-S)]

INTRODUCTION

Bowel symptoms (constipation and incontinence) are frequent in patients with a neurologic disease, but rarely assessed in rehabilitation centres.

AIM

To study the prevalence of neurogenic bowel dysfunction (NBD) in those patients, and to assess its severity with the Patient Global Impression of Severity (PGI-S).

MATERIAL

Prospective study by questionnaires, with the Neurogenic Bowel Dysfunction Score (0-47) and the PGI-S, a 1-item questionnaire (absent, mild, moderate, severe) for the severity of the bowel symptoms, and the Bristol Stool Chart for stool consistency. All patients presenting a chronic (>2months) neurological disease were included.

RESULTS

Inclusion of 169 patients, 97 with spinal cord injury, 42 with multiple sclerosis and 30 with hemiplegia. In each population, prevalence of constipation was 67 %, 45 % and 17 %, of pelvic floor dyssynergia 82 %, 45 % and 27 %, and leakages (gas or stools) de 74 %, 48 % and 43 %, respectively. Moderate to severe bowel symptoms were seen in 61 % of spinal cord injury, 43 % of multiple sclerosis and 23 % of hemiplegic patients, with NBD scores of 11.9±6.5, 5.7±4.9 and 3.7±4.2, respectively (P<0.01). There was a significant relation between PGI-S and NBD score (P<0.01). Significant lower NBD scores were associated with normal stool consistency (Bristol type 3 or 4) (P<0.01). In case of severe bowel symptoms, the use of transanal irrigation was hampered by patients' motivation and acceptation, and their autonomy.

CONCLUSION

PGI-S and Bristol Stool Chart are reliable tools to assess the presence of bowel symptoms in clinical practice.

Predictors of outcome for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia in men with spinal cord injury

STUDY DESIGN

This is a retrospective study.

OBJECTIVES

The objective of this study was to determine outcome predictors for urethral injection of botulinum toxin to treat detrusor sphincter dyssynergia (DSD) in patients with spinal cord injury.

METHODS

Botulinum toxin type A (100 Units Botox, Allergan) was injected into the external urethral sphincter using a transperineal approach under EMG guidance. Treatment was indicated if DSD was found on urodynamic testing with a post-void residual volume (PVR) above 100 ml. Urodynamic tests and cystourethrograms were performed at baseline. Dysuria (scale of 1-5) and PVR (48- h bladder diary) were evaluated at baseline and 1 month. The outcome was deemed excellent when PVR was equal to or <100 ml and 20%, and dysuria rated <3.

RESULTS

Seventy-two men with tetraplegia and 27 with paraplegia were included. There were significant reductions in PVR (from 227 to 97 ml and 63% to 27%) and dysuria (from 4.3 to 2.3). Excellent outcomes were found in 48 patients (48%), and the duration of effectiveness was 6.5 months. The need for catheterisation was decreased or eliminated in 18 patients. Vesicoureteral reflux disappeared in some patients. Poor outcome was significantly related to the presence of bladder neck dyssynergia and the absence of detrusor contraction in standard cystometry. Outcome was also related to the severity of DSD, with a strong correlation between PVR before and after injection (r=0.58). Injections were repeated in 36 patients and yielded similar outcomes in most cases (89%).

CONCLUSIONS

Detrusor contractions (odds ratio=8.6) and normal bladder neck activity (odds ratio=7.1) are strong predictors of excellent outcome.

A chain-of-states acceleration method for the efficient location of minimum energy paths

We describe a robust and efficient chain-of-states method for computing Minimum Energy Paths (MEPs) associated to barrier-crossing events in poly-atomic systems, which we call the acceleration method. The path is parametrized in terms of a continuous variable t ∈ [0, 1] that plays the role of time. In contrast to previous chain-of-states algorithms such as the nudged elastic band or string methods, where the positions of the states in the chain are taken as variational parameters in the search for the MEP, our strategy is to formulate the problem in terms of the second derivatives of the coordinates with respect to t, i.e., the state accelerations. We show this to result in a very simple and efficient method for determining the MEP. We describe the application of the method to a series of test cases, including two low-dimensional problems and the Stone-Wales transformation in C60.

Are oxybutynin and trospium efficacious in the treatment of detrusor overactivity in spinal cord injury patients?

OBJECTIVES

To evaluate the efficacy of anticholinergic agents in the treatment of neurogenic overactive bladder (NOAB) and neurogenic detrusor overactivity (NDO) in spinal cord injury (SCI) patients on clean intermittent catheterisation (CIC).

METHODS

Chronic suprasacral SCI patients on CIC presenting with at least one urinary leakage a day were included. Urodynamics and voiding diaries were performed at baseline and 1 month follow-up. In case of NDO at baseline, an anticholinergic drug was prescribed.

RESULTS

The 231 SCI patients presented with one to five urinary leakages per day (mean 2.1). Urodynamics showed NDO in all patients. A new anticholinergic treatment was started in all, either in monotherapy (134 patients) or in association with the existing anticholinergic drug (oxybutynin+trospium bitherapy, 97 patients). The mean maximum bladder capacity significantly increased from 225 to 441 ml, and the mean involuntary detrusor contractions (IDC) significantly decreased from 67 to 41 cm H2O. Only 75 SCI patients (32%) were fully continent. However, 25 out of these 75 patients showed persistent NDO, with amplitudes of IDC above 40 cm H2O in 12 patients. Incontinence was still found in 156 SCI patients (67%), with an average of 1,2 leakages a day. In 100 patients, amplitudes of IDC remained above 40 cm H2O. There was no statistical difference between patients on anticholinergic monotherapy or bitherapy at follow-up.

CONCLUSION

Anticholinergic treatment is not always satisfactory in terms of control of NDO and rarely allows full continence. Urodynamic follow-up is mandatory in all patients, even in those showing clinical continence.

Anomalous nuclear quantum effects in ice

One striking anomaly of water ice has been largely neglected and never explained. Replacing hydrogen (1H) by deuterium (2H) causes ice to expand, whereas the normal isotope effect is volume contraction with increased mass. Furthermore, the anomaly increases with temperature T, even though a normal isotope shift should decrease with T and vanish when T is high enough to use classical nuclear motions. In this study, we show that these effects are very well described by ab initio density-functional theory. Our theoretical modeling explains these anomalies, and allows us to predict and to experimentally confirm a counter effect, namely, that replacement of 16O by 18O causes a normal lattice contraction.

Ejaculatory dysfunction in spinal cord injury men is suggestive of dyssynergic ejaculation

Spinal cord injury (SCI) is associated with impaired ejaculation. After SCI, more stimuli may be required to trigger what remains of sexual reflexes. Penile vibratory stimulation (PVS) induces a strong afferent nerve stimulation and intense activation of the autonomic nervous system, and is considered first-line treatment. Oral midodrine may come as an adjunct to PVS and enhance the success rate. Electroejaculation (EEJ) is successful in most cases of failed PVS. The typical PVS semen characteristics in chronic SCI men demonstrate a normal mean total sperm count, but a low motility rate. Significantly lower sperm motility rates and total motile sperm counts are seen in EEJ compared to PVS. The coordination between external and internal sphincters is essential. In case of a supraconal lesion, a dyssynergic ejaculation may occur, with imbalance between expulsion of the ejaculatory fluid out the prostatic urethra and impaired relaxation of the urethral external sphincter. This leads to incomplete or absent antegrade ejaculation and would explain the high percentage of retrograde ejaculation and the low ejaculate volume observed in SCI men. In some cases, retrograde ejaculation could simply refer to a fraction of ejaculate present in the posterior urethra.

Linear Scaling DFT Calculations with Numerical Atomic Orbitals

We have recently developed a method to perform Density Functional Theory calculations in systems with a very large number of atoms, which is based on the use of numerical atomic orbitals as basis sets. The method incorporates Order-N techniques both in the calculation of the Kohn-Sham hamiltonian matrix elements and in the solution of the wave functions, which make the CPU time and memory to scale linearly with the number of atoms, allowing calculations in very large system. In this work, we present results on several test systems to show that the approach and the basis sets used with our method are able to provide an accuracy similar to that of other standard DFT techniques.

Mixed Approach to Incorporate Self-Consistency into Order-N LCAO Methods

We present a method for selfconsistent Density Functional Theory calculations in which the effort required is proportional to the size of the system, thus allowing the aplication to problems with a very large size. The method is based on the LCAO approximation, and uses a mixed approach to obtain the Hamiltonian integrals between atomic orbitals with Order-N effort. We show the performance and the convergence properties of the method in several silicon and carbon systems, and in a DNA periodic chain.

In-situ diffusion of HTO, 22Na+, Cs+ and I- in Opalinus Clay at the Mont Terri underground rock laboratory

The diffusion properties of the Opalinus Clay were studied in the underground research laboratory at Mont Terri (Canton Jura, Switzerland) and the results were compared with diffusion data measured in the laboratory on small-scale samples. The diffusion of HTO, 22Na+, Cs+ and I- were investigated for a period of 10 months. The diffusion equipment used in the field experiment was designed in such a way that a solution of tracers was circulated through a sintered metal screen placed at the end of a borehole drilled in the formation. The concentration decrease caused by the diffusion of tracers into the rock could be followed with time and allowed first estimations of the effective diffusion coefficient. After 10 months, the diffusion zone was overcored and the tracer profiles measured. From these profiles, effective diffusion coefficients and rock capacity factors could be extracted by applying a two-dimensional transport model including diffusion and sorption. The simulations were done with the reactive transport code CRUNCH. In addition, results obtained from through-diffusion experiments on small-sized samples with HTO, 36Cl- and 22Na+ are presented and compared with the in situ data. In all cases, excellent agreement between the two data sets exists. Results for Cs+ indicated five times higher diffusion rates relative to HTO. Corresponding laboratory diffusion measurements are still lacking. However, our Cs+ data are in qualitative agreement with through-diffusion data for Callovo–Oxfordian argillite rock samples, which also indicate significantly higher effective diffusivities for Cs+ relative to HTO.

Comparison of Application Methods of Systemic Fungicides to Suppress Branch Cankers in Clementine Trees Caused by Phytophthora citrophthora

Since 2002, considerable losses of Clementine trees (Citrus clementina) have been observed in Spain due to Phytophthora branch canker of citrus caused by Phytophthora citrophthora. Due to the low efficiency of the available cultural and genetic control measures, application of fungicides is required for economic management of the disease. Fosetyl-Al, metalaxyl, and its enantiomer mefenoxam are the only systemic fungicides registered for control of Phytophthora diseases in Spain. However, their efficacy has not been tested against Phytophthora branch canker. Greenhouse and field experiments were conducted for 3 years in Spain to evaluate the ability of these fungicides and application methods to reduce lesion expansion. Nevertheless, with the inoculation technique used, it was not possible to evaluate the protective activity of fungicides, which can play an important role in their performance under field conditions. None of the fungicide treatments inhibited lesion expansion when applications were made on a curative basis. The residual effect was better on young than on mature trees. Paint treatments were generally more effective in reducing lesion expansion that drip chemigation or foliar sprays. However, this application method is laborious and becomes uneconomical in Spain. Trunk and branch sprays as well as long-term programs of foliar sprays or drip chemigation for control of spring and autumn infections are proposed as targets for future research.

The SIESTA method; developments and applicability

Recent developments in and around the SIESTA method of first-principles simulation of condensed matter are described and reviewed, with emphasis on (i) the applicability of the method for large and varied systems, (ii) efficient basis sets for the standards of accuracy of density-functional methods, (iii) new implementations, and (iv) extensions beyond ground-state calculations.

The SIESTA method; developments and applicability

Recent developments in and around the SIESTA method of first-principles simulation of condensed matter are described and reviewed, with emphasis on (i) the applicability of the method for large and varied systems, (ii) efficient basis sets for the standards of accuracy of density-functional methods, (iii) new implementations, and (iv) extensions beyond ground-state calculations.

Comparison betweenin situand laboratory diffusion studies of HTO and halides in Opalinus Clay from the Mont Terri

A long-term single-borehole diffusion experiment (DI) using tritiated water (HTO) and stable iodide (127I-) was carried out In the Opalinus Clay of the Mont Terri Underground Rock Laboratory (URL). Diffusion coefficientsDLand accessible porosity for HTO,36Cl-and125I-were also measured on centimetric Opalinus clay samples using the through diffusion technique. The evolution of tritium and iodide concentration in the injection system over time andin situprofiles were interpreted with a 3-D numerical simulation. A detailed analysis of the results pointed out the effect of a disturbed zone around the borehole with higher diffusion coefficients. The best estimate values for HTO and iodide in the undisturbed rock areDL= 5×10-11m2/s andDL= 1.5×10-11m2/s respectively. For the laboratory tests,DLvalues for HTO are in the range of 5×10-11m2/s to 8.5×10-11m2/s. For125I-and36Cl-the measured values areDL=νmber1.4×10-11andDL=1.6×10-11m2/s respectively.

All HTO results obtained with a through diffusion technique are within the same range as those obtained in thein situtests. TheDLvalues obtained in diffusion cells with125I-and36Cl-and the value drawn from the interpretation of stable127I-concentration profiles from thein situtests are very close. In fact, some significant uncertainties could be identified (i.e.a likely chemical retention of iodide on argillites, effect of the disturbed zone).

Simulation of remediation alternatives for a137Cs contaminated soil

We analyze remediation alternatives for a soil contaminated with137Cs, which sorbs strongly to clay aggregates where water flux is negligible. The mobile portion of the soil (macropores) retains little water and cesium. Some of the remediation alternatives involve infiltration of seawater enriched with KCl, to promote mobilization of Cs through exchange with K. Therefore, a fully coupled reactive transport model is used to test these alternatives. We conclude that flushing is a viable alternative, provided that some recommendations, derived from the modelling exercise are followed. These include high rate periodic infiltration and draining, as well as performing infiltration from independent cells to limit the effect of preferential flowpaths.

Midodrine improves ejaculation in spinal cord injured men

PURPOSE

We evaluated the effect of the alpha1-adrenergic agonist midodrine given orally for anejaculation in spinal cord injured men.

MATERIALS AND METHODS

A total of 185 spinal cord injured patients who reported absent ejaculation during sexual intercourse and who failed to respond to penile vibratory stimulation were treated with midodrine 30 to 120 minutes before a new stimulation. The procedure was repeated weekly, increasing doses by 7.5 mg to a maximum of 30 mg. Cardiovascular effects were monitored throughout the procedure.

RESULTS

Antegrade or retrograde ejaculation was achieved in 102 spinal cord injured men (64.6%). A positive response was more frequent in patients with complete lesions (American Spinal Injury Association A) and upper motor neuron lesions above T10. Midodrine induced a significant but moderate increase (maximum 10 mm Hg) in mean arterial pressure in all patients. The highest systolic blood pressure (more than 200 mm Hg) was seen in patients with quadriplegia. No other significant side effect was recorded. The average dose of midodrine required for ejaculation was 18.7 mg.

CONCLUSIONS

Midodrine is a safe and efficient adjunct to penile vibratory stimulation for anejaculation in spinal cord injured patients.

Chapitre A - Les dysfonctions sexuelles masculines et leurs traitements en neuro-urologie

The management of sexual dysfunction has been revolutionized over recent years with the arrival of new treatments for erectile dysfunction. In parallel, groups specialized in neurosexology have gradually emerged in order to improve the patient's fertility. This article presents the disorders most frequently encountered in spinal cord injury and the main approaches to management.

Chapitre B - L’incontinence anale et les troubles digestifs et leurs traitements en neuro-urologie

Anal incontinence and gastrointestinal disorders are one of the major causes of impaired quality of life in patients with neurological disease. Patients are very often too embarrassed to spontaneously talk about these problems and problems of chronic constipation can lead to microbial maceration, a known risk factor for urinary tract infection. In this article, the authors review the physiology of defecation and describe the main disorders observed in the various neurological diseases and their management.

Phosphodiesterase inhibitors in the treatment of erectile dysfunction in spinal cord-injured men

STUDY DESIGN

Open, before-after study.

OBJECTIVE

To assess the efficacy and safety of phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction (ED) in spinal cord-injured (SCI) patients.

SETTING

Home- and clinic-based assessments in the outpatient department at the Centre Bouffard Vercelli, Cerbère France.

METHODS

Clinic trials with Sildenafil (Viagra) on 120 patients, Tadalafil (Cialis) on 54 patients and Vardenafil (Levitra) on 66 patients were performed. Flexible doses of PDE5 inhibitors were given depending on efficacy and tolerability, from 50 to 100 mg for Sildenafil, and from 10 to 20 mg for Vardenafil and Tadalafil. Each trial was performed after a week's interval. The efficacy was self-assessed by the patients on a six-point quantitative scale assessment. The response to treatment was assessed at home in 90 patients (57 patients on Sildenafil, 12 patients on Vardenafil and 21 patients on Tadalafil) using the International Index of Erectile Function (IIEF).

RESULTS

In clinic trials, PDE5 inhibitors were effective (rigidity enough for penetration) in 85% of the patients on Sildenafil, 74% of the patients on Vardenafil and 72% of the patients on Tadalafil. The mean duration of erection was 34, 28 and 26 min, respectively. Adverse effects were mild, usually attenuated with continued dosing. More than 70% of the patients on Vardenafil and Tadalafil required higher doses of 20 mg, whereas 50 mg of Sildenafil was effective in 55% of the patients. Two-thirds of our patients on Tadalafil reported a duration of action longer than 24 h. The presence of an upper motor neuron lesion was significantly associated with therapeutic success, lower motor neuron lesions and cauda equina patients were poor responders. Other variables such as completeness of lesion had no impact. In the follow-up visits, the IIEF global scores and three IIEF domains (erectile function, intercourse satisfaction and overall satisfaction) were significantly improved in all patients. Patients on Sildenafil showed a significant improvement of orgasmic function, ejaculation (Question 9) and orgasm (Question 10).

CONCLUSION

Sildenafil, Vardenafil and Tadalafil are all effective and well-tolerated treatments for ED in SCI patients. Although no statistical analysis could be applied on these data, these results might indicate that Sildenafil is more effective in treating ED. Clinic trials are important for proper dose titration and appropriate education of the patients.

Routine positron emission tomography (PET) and selective mediastinoscopy is as good as routine mediastinoscopy to rule out N2 disease in non-small cell lung cancer (NSCLC)

7031

Background: To evaluate the presence of mediastinal lymph node spread of NSCLC after changing the clinical staging protocol from routine to selective surgical mediastinal exploration (SME) based on PET. Methods: From 1994 to 2003, routine SME (mediastinoscopy, parasternal mediastinotomy or extended cervical mediastinoscopy) was performed to 655 patients (pts) with NSCLC as the last clinical staging procedure prior to thoracotomy. Those with no mediastinal involvement underwent thoracotomy with lung resection (T) and systematic nodal dissection (SND). From 2004, PET was routinely done in 90 pts and SME was reserved for those with positive mediastinal or hiliar uptake on PET, mediastinal lymph node diameter greater than 1cm in shorter axis on computerized tomography, and in tumors contacting with the mediastinum. All other pts and those with negative SME underwent T and SND. Results: Among 655 pts studied between 1994 and 2003, 236 (36%) had positive SME; 419 underwent T and SND and 40 (6.1%) were classsified as pN2. Of the 90 evaluable pts with PET, 27 had increased uptake in the mediastinum an 17 had positive SME; the remaining 10 ptes with negative SME underwent T and SND and 7 of them were found to have no nodal disease (false positive PET), but three of them were found to have nodal disease. Of the 63 pts with no uptake in the mediastinum, 29 underwent SME for reasons stated above: 5 SME was positive; in 24 SME was negative and the patients underwent T and SND: 21 were pN0 and 3 were pN2. Only 1 tumor of the remaining 34 pts with negative PET who underwent T and SND without SME was classified pN2. Additionally, in 1 pt PET detected N2 disease but not N3. 4 (4.5%) pts with pN2 disease were clinically understaged (negative PET and negative SME) and underwent thoracotomy. 3 pts with positive PET who underwent SME were classified pN0, but they were pN2 (false negative SME). In total, 7 (7.8%) pts with pN2 disease were clinically understaged and underwent T. This rate is not statisticallly different from the 6.1% pN2 tumor found after routine SME. Conclusions: In this preliminary study, this new clinical staging protocol with routine PET and selective SME saves up to 35% of SME and yields a similar rate of pN2 disease compared to routine SME.

No significant financial relationships to disclose.

Micturition syncope following intermittent catheterisation in a tetraplegic patient

STUDY DESIGN

Case report.

OBJECTIVE

To describe a case of severe hypotension and occasional syncope following intermittent catheterisations in a tetraplegic patient.

SETTING

Department of Spinal Injuries, Berck, France.

CASE REPORT

A 47-year-old man presenting with C7 ASIA B tetraplegia for 9 months, developed episodes of severe hypotension and occasional syncope following intermittent catheterisations. These episodes were observed in the minutes following the catheterisations performed in the sitting position, associating hypotension and bradycardia. He was on intermittent catheterisation, had a history of bladder hyper-reflexia with some episodes of symptomatic urinary tract infections, of mild autonomic dysreflexia (headache, sweating) on high bladder distension, of mild orthostatic hypotension, and of reactional depression to the trauma, treated with fluoxetine hydrochloride (Prozac).

RESULTS

The progressive removal of the fluoxetine hydrochloride (Prozac) led to disappearance of the syncope 1 week later. Mild hypotension after catheterisations still persisted though, but completely disappeared a few months later after further management of bladder hyper-reflexia with botulinum-A toxin injections into the detrusor.

CONCLUSION

In spinal cord injury patients at risk of micturition syncope, care should be taken to achieve a gradual decrease in bladder volume, to control bladder hyper-reflexia and to avoid any medications with orthostatic hypotension's side effects.

Les troubles vésicosphinctériens de la maladie de Parkinson

Parkinson's disease related to degeneration of the extrapyramidal structures is characterized in its typical form by the classic triad of tremors, rigidity and akinesia, constituting Parkinson's syndrome. These are combined with neurovegetative disorders, responsible for sexual and bladder sphincter dysfunction. The Latter occurs in from 30% to 90% of cases, depending on the stage of progression of the disease. The dopamine deficiency in the nigrostriataL tract leads to a lifting of the inhibition which is probably the cause of the bladder hyperreflexia. Irritative signs are most frequently observed. The flowmetry data are contradictory, depending on the publication whereas the bladder overactivity, objectified by cystomanometry, is described in most of the studies although certain authors report, on the contrary, bladder hypoactivity. Conflicting data have also been published on bladder sphincter dyssynergia although in most studies, micturition was described as synergic in Parkinson's disease patients. L-dopa, the main drug for Parkinson's disease, has, according to the publication, either no action, or contradictory effects with bladder hypoactivity or hyperactivity. Anticholinergics are effective on overactive bladder, the alphablockers on the urethral hypertonia at the price of a higher risk of arterial hypotension in this diathesis. The indication for prostatic surgery must be carefully considered and preceded by precise clinical, urodynamic and sometimes electromyography evaluation. There is a high risk of post surgical incontinence. Endourethral prostheses provide an attractive alternative in the case of prostatic obstruction.

Diffusion of HTO, 36Cl- and 125I- in Opalinus Clay samples from Mont Terri. Effect of confining pressure

Diffusion coefficients (T=23 +/- 2 degrees C) and accessible porosities for HTO, 36Cl(-) and 125I(-) were measured on Opalinus Clay (OPA) samples from the Mont Terri Underground Rock Laboratory (URL) using the through-diffusion technique. The direction of transport (diffusion) was perpendicular to bedding. Special cells that allowed the application of confining pressure were designed and constructed. The pressures ranged from 1 to 5 MPa, the latter value simulating the overburden at the Mont Terri URL (about 200 m). The test solution used in the experiments was a synthetic version of the Opalinus Clay pore water, which has Na(+) and Cl(-) as the main components (I=0.42 M). The measured values of the effective diffusion coefficients (D(e)) and rock capacity factors (alpha) are: D(e)=1.2-1.5 x 10(-11) m(2) s(-1) and alpha=0.09-0.11 for HTO, D(e)=4.0-5.5 x 10(-12) m(2) s(-1) and alpha=0.05 for 36Cl(-) and D(e)=3.2-4.6 x 10(-12) m(2) s(-1) and alpha=0.07-0.10 for 125I(-). For non-sorbing tracers (HTO, 36Cl) the rock capacity factor alpha is equal to the diffusion-accessible porosity epsilon. The experimental results showed that pressure only had a small effect on the value of the diffusion coefficients. Increasing the pressure from 1 to 5 MPa resulted in a decrease of the diffusion coefficient of approximately 17% for HTO, approximately 28% for 36Cl(-) and approximately 30% for 125I(-). Moreover, the diffusion coefficients for 36Cl(-) and 125I(-) are smaller than for HTO, which is consistent with an effect arising from anion exclusion. The diffusion coefficients of HTO and 125I(-) measured in this study are in good agreement with recent measurements at three other laboratories performed within the framework of a laboratory comparison exercise. The values of the diffusion-accessible porosities show a larger degree of scatter.

Modelling of nonreactive tracer dipole tests in a shear zone at the Grimsel test site

The investigation of the migration of a high pH plume in a fractured shear zone is foreseen by a long-term experiment at the Grimsel rock laboratory. In order to characterise the initial conditions for the long-term experiment and to evaluate an optimal hydraulic in situ set-up, several dipole experiments with nonreacting tracers have been performed. The dipole experiments differ in geometry, pumping rates and orientation to the background water flow. Several single and double-porosity models have been applied to fit the results of these dipole tracer tests in order to extract values for some transport parameters and discriminate for certain transport processes. A two-dimensional porous medium approach was successfully used to fit tracer breakthrough curves measured for a dipole experiment. A model based on a one-dimensional dual porous medium approach was also successful, although the applied hydraulic dipole, with similar injection and extraction rates, suggests the existence of an extended two-dimensional flow field. For the two-dimensional porous medium approach, tracer breakthrough could only be fitted with a complex flow field geometry within the heterogeneous fractured shear zone. The heterogeneity was generated by heterogeneous porosity and hydraulic permeability distributions. Predictions for further dipole geometries and a sorbing tracer have been calculated by means of both models using the flow and transport parameters deduced from fits for a single dipole experiment. This allows for comparison with the measured breakthrough of sorbing tracers. The foreseen experiment with sorbing (radionuclide) tracers will help decide on the appropriate approach that should be used to describe such dipole experiments in this shear zone. Additionally, the migration and spreading of a solution with high pH has been calculated taking into account mineral dissolution and precipitation in a two-dimensional porous medium approach in order to estimate the amount and character of the mineral reactions induced by the interaction between the high pH solution and the rock.

The effect of coupled transport phenomena in the Opalinus Clay and implications for radionuclide transport

In this study, the potential effects of coupled transport phenomena on radionuclide transport in the vicinity of a repository for vitrified high-level radioactive waste (HLW) and spent nuclear fuel (SF) hosted by the Opalinus Clay in Switzerland, at times equal to or greater than the expected lifetime of the waste canisters (about 1000 years), are addressed. The solute fluxes associated with advection, chemical diffusion, thermal and chemical osmosis, hyperfiltration and thermal diffusion have been incorporated into a simple one-dimensional transport equation. The analytical solution of this equation, with appropriate parameters. shows that thermal osmosis is the only coupled transport mechanism that could, on its own, have a strong effect on repository performance. Based on the results from the analytical model, two-dimensional finite-difference models incorporating advection and thermal osmosis, and taking conservation of fluid mass into account, have been formulated. The results show that, under the conditions in the vicinity of the repository at the time scales of interest, and due to the constraints imposed by conservation of fluid mass, the advective component of flow will oppose and cancel the thermal-osmotic component. The overall conclusion is that coupled phenomena will only have a very minor impact on radionuclide transport in the Opalinus Clay, in terms of fluid and solute fluxes, at least under the conditions prevailing at times equal to or greater than the expected lifetime of the waste canisters (about 1000 years).

Hemochromatosis gene variants in patients with cardiomyopathy

Iron depletion was suggested to be protective against the development of ischemic heart disease. Population studies have led to conflicting results, and such an association has not been addressed in patients with heart failure due to cardiomyopathy. We studied the distribution of hemochromatosis-related mutations in 319 patients with heart failure due to cardiomyopathy of different etiologies. The genotypic distribution showed a significantly higher prevalence of heterozygotes for the C282Y mutation in patients with ischemic cardiomyopathy than in patients with cardiomyopathy of nonischemic etiologies (p = 0.0036). The frequency of the D63 mutation was not significantly different between ischemic versus nonischemic groups. In multiple logistic regression models adjusted for age, sex, ethnicity, and different degrees of disease progression, there was a strong and significant association of the C282Y mutation with ischemic cardiomyopathy compared with the nonischemic group (odds ratio 6.64, 95% confidence interval 1.71 to 25.73, after adjustment). In our sample, genetic variation in the HFE gene was associated with ischemic cardiomyopathy. Such association merits further study regarding its value as a prognostic marker in patients with ischemic heart disease.

Absence of dc-conductivity in lambda-DNA

The electrical conductivity of biomaterials on a molecular scale is of fundamental interest in the life sciences. We perform first principles electronic structure calculations, which clearly indicate that lambda-DNA chains should present large resistance values. We also present two direct procedures to measure electrical currents through DNA molecules adsorbed on mica. The lower limit for the resistivity is 10(6) Omega . cm, in agreement with our calculations. We also show that low energy electron bombardment induces a rapid contamination and dramatically affects the measured conductivity, thus providing an explanation to recent reports of high DNA conductivity.

Dose-ranging study of tolterodine in patients with detrusor hyperreflexia

Tolterodine is a potent antimuscarinic agent specifically developed for the treatment of urinary urge incontinence and other symptoms related to the overactive bladder. In order to assess the optimum dosage for use in future clinical studies, a double-blind, randomized, placebo-controlled, parallel-group, multicenter study was performed in 90 patients with detrusor hyperreflexia and symptoms of urinary urgency, frequency, and/or urge incontinence. Urodynamic variables, micturition diary variables, and subjective urinary symptoms were measured before and after 2 weeks' treatment with either placebo or tolterodine 0.5, 1, 2, or 4 mg twice daily (bd). Serum drug concentrations, electrocardiogram recordings, blood pressure, and incidence of adverse events were also assessed. Linear regression analysis showed a significant dose-response relationship for several clinically relevant urodynamic variables, while there was a trend towards an improvement in micturition diary variables and subjective assessment of symptoms with increasing dosages of tolterodine. There were no safety or tolerability concerns regarding any of the dosages of tolterodine investigated, although 2 patients treated with a dosage of 4 mg bd experienced urinary retention that necessitated dosage reduction. The results of this study suggest that tolterodine is well-tolerated and exerts a dose-dependent effect on bladder function in patients with detrusor hyperreflexia. The optimum dosage of tolterodine for use in future studies is 1-2 mg bd.

Is there a place for pudendal nerve maximal electrical stimulation for the treatment of detrusor hyperreflexia in spinal cord injury patients?

The aim of the study is to determine whether pudendal nerve maximal electrical stimulation (MES) could represent an alternative treatment for detrusor hyperreflexia in spinal cord injury (SCI) patients. Six suprasacral SCI patients participated in the study. The treatment consisted of daily stimulation periods of 20 min, repeated five times a week, during 4 weeks, with continuous electrical stimulation of the penis or of the clitoris via bipolar surface electrodes (rectangular stimuli of 0.5 ms pulse duration, 5 Hz frequency), with the maximum tolerable stimulation strength (under the level of pain). In two patients, additional stimulation was administrated by means of an anal plug during the last 2 weeks. The stimulus strengths ranged from 35 to 99 mA (mean 54 mA). One patient stopped MES after 2 weeks. At the end of the treatment, neither the cystometric bladder capacities (153 ml vs 157 ml) nor the micturition charts had significantly improved for the five remaining patients. Only two patients experienced non lasting improvement of nocturia at some time of the treatment. In conclusion, we were not able to demonstrate the efficacy of MES in inhibiting detrusor hyperreflexia in SCI patients. To reach therapeutic effects, other parameters may be needed, such as higher stimulation strengths (currents above or equal to 99 mA) or other currents (such as interferential therapy). Chronic stimulation with external or implanted electrodes using lower currents may represent an alternative.

Special characteristics of osteoid osteoma in the proximal phalanx

We report two cases of osteoid osteoma in the proximal phalanx. This is an uncommon location for the lesion and it has special clinical and radiological features. Both cases were successfully treated when an 'en bloc' excision of the lesion, including the nidus, was performed. Four operations were required in the first case.

Ovarian follicular dynamics in nelore breed () cattle

The most common beef cattle raised in Brazil is the Nelore breed (Bos indicus). Information obtained by ultrasonography on follicular growth in Bos taurus cattle has been accumulating rapidly. However, there are few publications to date on follicular development in Bos indicus breeds. The follicular dynamics in Nelore heifers and cows during natural or prostaglandin (PG)-induced estrous cycle were studied. From the detection of estrus onward, all animals were examined daily by ultrasonography for one (n = 35) or two (n = 10) consecutive estrous cycles. The follicular dynamic in Nelore cattle was characterized by the predominance of 2 follicular waves in the cows (83.3%, n = 18, P < 0.05) and 3 waves in the heifers (64.7%, n = 16, P < 0.05). Most of the cattle observed over 2 consecutive estrous cycles presented the same pattern of follicular waves in the first and second cycle, and only 30% showed variation in the number of waves from one cycle to the other. Most of the follicular parameters analyzed were not affected by PG treatment or age but were altered by follicular waves. Consequently, data on cows and heifers were combined according to the number of follicular waves. The ovulatory follicle was larger than the other dominant follicles (P < 0.05), and the ovulatory wave was shorter than the preceding waves (P < 0.05). The interovulatory interval was longer in animals showing 3 waves than those exhibiting 2 waves (P < 0.05). Maximum diameter of the dominant follicle (around 11 mm) and of the corpus luteum (CL, approximately 17 mm) were smaller than those reported for European breeds. In conclusion, the results demonstrate that although the dominant follicle and corpus luteum are smaller than in European breeds, the follicular dynamics in Nelore cattle were similar to those observed in European breeds and were characterized by 2 or 3 follicular waves for cows and heifers, respectively, during the natural or prostaglandin-induced estrous cycle.

Medial rotational tibial osteotomy for patellar instability secondary to lateral tibial torsion

We report 35 medial rotational osteotomies in 25 patients with chronic disability suggesting patello-femoral subluxation secondary to lateral tibial torsion. None had responded to conservative measures or soft tissue operations. The osteotomy was transverse in 17 and oblique in 18. The follow up averaged 4.3 years (range 1 to 8 years). The alignment of the limb was assessed clinically, and by radiographs and CT scans. The results were good or excellent in 88.5%, fair in 5.7% and poor in 5.7%. Twenty-three patients were satisfied and 2 were not. The overall results have been satisfactory in athletes and those leading an active life.

Short-term effect of pudendal nerve electrical stimulation on detrusor hyperreflexia in spinal cord injury patients: importance of current strength

Twenty patients with chronic suprasacral spinal cord injury presenting with detrusor hyperreflexia were examined. In a preliminary study in ten patients we investigated the reproducibility of bladder capacity through the repetition of three cystometries. The effect of electrical stimulation (ES) on detrusor hyperreflexia was then investigated in ten patients during three consecutive cystometries, the first one without ES (baseline) and the other two with continuous ES of the dorsal penile or clitoris nerve via surface electrodes. Parameters of stimulation were 5 Hz frequency, 0.50 msec pulse duration, and stimulation strength of 1 and 2 times the bulbocavernosus reflex threshold. No significant differences in bladder capacity were found between the three consecutive cystometries without ES (respectively 97.0 ml, 101.5 ml and 105.6 ml). A current at the bulbocavernosus threshold (mean 24.4 mA) failed to induce a significant increase in bladder capacity compared to baseline (173.0 ml vs 155.5 ml, P = 0.17) whereas a current of twice the bulbocavernosus threshold (mean 48.9 mA) was highly significant (318.5 ml vs 155.5 ml, P < 0.007). ES of twice the threshold resulted in perineal contraction in all of the patients, the threshold ES never did. Our results emphasise the decisive roles of perineal contraction and of current strength for achieving short-term bladder inhibition in spinal cord injury patients. The carry-over effect may also be dependent on the current strength. If so, maximal pudendal ES could represent an alternative procedure in the treatment of detrusor hyperreflexia in these patients.