Urinary infections in patients with spinal cord injury

STUDY DESIGN

A retrospective study concerning urinary tract infections in spinal cord injury (SCI) patients.

OBJECTIVES

To check whether the regular (1/week) urine cultures allow a more accurate treatment of urinary tract infections in SCI patients compared to empiric treatment.

SETTING

Ghent University Hospital, East-Flanders, Belgium.

METHODS

Group 1: 24 tetraplegic patients; group 2: 22 paraplegic patients; group 3: 28 other polytrauma patients as controls. These groups were chosen as catheterisation and other voiding methods differ according to the underlying pathology.

RESULTS

An average of four clinically significant episodes of bacteriuria were found for groups 1 and 2, while group 3 experienced very few urinary infections. The mean species turnover of the first two groups was 2. No statistically significant difference was found in antibiotic-resistance patterns of organisms isolated.

CONCLUSION

Despite different catheterisation techniques in para- and tetraplegic patients, we conclude that: (1) the number of episodes of clinical significant nosocomial urinary infections is not different; (2) the mean species turnover is the same; (3) because of the species turnover, the value of regular urine cultures for 'documented' treatment of clinical relevant urinary infections seems to be limited. So urine culture could be performed less frequently or only when therapy becomes mandatory; (4) No oral antibiotic with superior activity was found: treatment is best started empirically (after sampling for urine culture) and adjusted to the resulting antibiotic sensitivity screening.

Bilateral S3 nerve stimulation, a minimally invasive alternative treatment for postoperative stress incontinence after implantation of an anterior root stimulator with posterior rhizotomy: a preliminary observation

STUDY DESIGN

A preliminary report.

OBJECTIVES

Urinary stress incontinence following implantation of an anterior root stimulator and a posterior rhizotomy is a rare complication which is difficult to treat. It is seen in patients with an open bladder neck (T9-L2 lesion). An artificial urinary sphincter is a possible treatment for this condition but has a higher failure rate in patients with neurogenic bladder disease and could complicate micturition.

SETTING

Ghent, Belgium.

METHODS

A male paraplegic patient (T9, complete lesion) aged 36 was suffering from severe urinary incontinence due to detrusor hyperreflexia. Preoperatively the bladder neck was closed on cystography. Following implantation (6/95) of an intradural anterior root stimulator with posterior rhizotomy, severe urinary stress incontinence presented. Bilateral S3 foramen leads were implanted and connected to a pulse generator.

RESULTS

The patient has been continent with continuous stimulation of both S3 roots for 4 years, and no fatigue of the levator muscles has been seen. Preoperative urodynamics are compared to results 3 years postoperatively.

CONCLUSION

Bilateral S3 stimulation is a feasible and minimally invasive treatment of urinary stress incontinence following implantation of an anterior root stimulator.

Pelvic floor function in patients with clinically complete spinal cord injury and its relation to constipation

PURPOSE

Constipation is a common problem in patients with spinal cord injury. The aim of this study is to analyze the role of pelvic floor dysfunction in the development of constipation.

METHODS

Twenty-five patients with clinically complete supraconal spinal cord injury were studied by means of colonic transit time, anal manometry, electrophysiologic testing, and sensory-evoked potentials.

RESULTS

Sixteen patients had prolonged total and segmental colonic transit times (Group C), and nine patients had normal colonic transit times (Group NC). Basal pressure and anal pressure during coughing, Valsalva's maneuver, and rectal distention were diminished in all patients, but no differences were observed between Group C and Group NC. Rectal sensation was preserved in eight patients, but this was not related to the absence of constipation. In seven of these eight patients, somatosensory-evoked potentials could be recorded, which indicated an incomplete cord lesion. Synergic relaxation of the pelvic floor during straining was never observed; dyssynergia was seen in ten (7 in Group C and 3 in Group NC; P = not significant) patients. Associated peripheral nerve damage was present in 40 percent of patients but did not predispose these patients to constipation.

CONCLUSIONS

Loss of rectal sensation, dyssynergic pelvic floor contraction during straining, associated peripheral nerve damage, and insufficient rise of intraabdominal pressure could not be held responsible for constipation as a result of spinal cord injury. A prolongation of the colonic transit time is the most important mechanism, and therapy should be directed toward it.

Constipation and other chronic gastrointestinal problems in spinal cord injury patients

From a questionnaire sent to 90 spinal cord injury (SCI) patients it is concluded that 58% of patients with a complete SCI above L2 suffer from constipation, defined as two or fewer bowel movements per week, or the use of aids such as laxatives, manual evacuation or enemas. Tetraplegic patients had the highest prevalence of constipation, while patients with low paraplegia were less prone to constipation. The use of anticholinergic drugs was found to predispose to constipation. Preserved rectal sensation did not influence the presence of constipation. Faecal incontinence was rare. Regular abdominal pain was present in one third of SCI patients and might be caused by an irritable bowel syndrome in 62% of these.

Diagnosis and localization of a complicated urinary tract infection in neurogenic bladder disease by tubular proteinuria and serum prostate specific antigen

INTRODUCTION

Urinary tract infection is the most frequent complication occurring in patients with spinal cord injuries and can cause renal failure and male infertility. We used the urinary alpha-1-microglobulin (alpha 1Mg) as a marker for pyelonephritis and the serum prostate specific antigen (PSA) as a marker for prostatitis with reference to the currently available methods. The aim of our study is (1) to differentiate between upper (pyelonephritis) and lower urinary tract infection (cystitis, prostatitis) in neurogenic bladder disease, (2) to determine if high (< or = 38.5 degrees C) fever in a neurogenic bladder disease patient was due to urological (prostatitis, pyelonephritis) causes or not.

PATIENTS AND METHODS

We evaluated 147 patients of whom 27 had acute pyelonephritis, 16 had prostatitis with fever, 13 had chronic pyelonephritis, 68 had cystitis; 23 were control patients of whom nine had fever (< or = 38.5 degrees C) and 14 did not. The diagnoses and localizations were made on the basis of clinical evidence, with a CT scan, urography, bladder wash-out tests, and five glass-specimen tests. The urinary alpha 1Mg was determined using latex enhanced immunonephelometry and the serum PSA was measured using RIA.

RESULTS

For the urinary alpha 1Mg, the sensitivity is 96% and the specificity 93% for the diagnosis of acute pyelonephritis. The serum PSA has a sensitivity of 69% and specificity of 96% in the diagnosis of prostatitis. The urinary alpha 1Mg has a sensitivity of 96% and a specificity of 56% and the serum PSA has a sensitivity of 68% and a specificity of 100% in the differential diagnosis of prostatitis and pyelonephritis. The best discriminative parameter between pyelonephritis and prostatitis was the urinary alpha 1Mg/serum PSA ratio with a sensitivity of 92% and specificity of 88%.

CONCLUSION

Upper-tract infection with fever can be diagnosed in neurogenic bladder disease by determining the urinary alpha 1Mg. In male patients, the serum PSA should be determined to distinguish upper-tract infection from prostatitis. High fever does not significantly influence our parameters so that we can differentiate whether or not high fever is due to urological causes.

Use of electrical stimulation in brain-injured patients: a case report

After failure of other therapeutic measures, electrical stimulation was applied to promote gait rehabilitation in a patient with severe brain injury and complete left hemiplegia. The favourable results reported in the literature were confirmed. Despite the long interval between injury and institution of electrical stimulation, independent ambulation was quickly restored.

Urinary incontinence in brain injury

In the rehabilitation of severely brain-injured patients, solving urinary incontinence poses a therapeutic challenge. From this study it appears that incontinence does not always result from impaired neuropsychological functioning. If habituation procedures fail, an underlying organic cause (usually detrusor hyperactivity with synergic sphincter action) for persistent urinary incontinence can be demonstrated in a large number of patients. In patients with a severe pelvic fracture a pudendal nerve lesion must be ruled out.

Association between muscle trauma and heterotopic ossification in spinal cord injured patients: reflections on their causal relationship and the diagnostic value of ultrasonography

Paraplegic patients presenting with a subacute limitation of hip joint mobility were subjected to serial sonographic examinations. In four patients the initial sonographic study disclosed discontinuity with fluid collection in the psoas muscle, which was diagnostic of a traumatic muscle rupture. All four patients subsequently developed sonographic and radiographic evidence of heterotopic ossification. Our findings confirm that ultrasonography is an easy and inexpensive screening method for the early diagnosis of heterotopic ossification. The sonographic results obtained in these four paraplegic patients are indicative of a possible traumatic origin of heterotopic ossification around the hip.

Bone mineral status in paraplegic patients who do or do not perform standing

Bone mineral density (BMD) was assessed by dual-photon X-ray absorptiometry at the lumbar spine (L3, L4), the proximal femur and the femoral shaft, and by single-photon absorptiometry at the forearm in 53 patients with complete traumatic paraplegia of at least 1 year's duration and in age- and sex-matched healthy controls. The patients did (n = 38) or did not (n = 15) regularly perform passive weightbearing standing with the aid of a standing device. Compared with the controls, the BMD of paraplegic patients was preserved in the lumbar spine and was markedly decreased in the proximal femur (33%) and the femoral shaft (25%). When considering all patients performing standing, they had a better-preserved BMD at the femoral shaft (p = 0.009), but not at the proximal femur, than patients not performing standing. BMD at the lumbar spine (L3, L4) was marginally higher in the standing group (significant only for L3; p = 0.040). A subgroup of patients performing standing with use of long leg braces had a significantly higher BMD at the proximal femur than patients using a standing frame or a standing wheelchair (p = 0.030). The present results suggest that passive mechanical loading can have a beneficial effect on the preservation of bone mass in osteoporosis found in paraplegics.

Reconstruction of the upper extremity in tetraplegia: functional assessment, surgical procedures and rehabilitation

The results of 22 procedures (8 for elbow extension, 14 for hand rehabilitation) on the upper limb in tetraplegia are reported. To evaluate the effect of surgery an objective hand function test is presented. The few complications after surgery must be attributed to the material used.

Environmental control and social integration of a high-lesion tetraplegic patient: case report

In the rehabilitation of high lesion tetraplegic patients, we should always aim at re-integration into the family. For these patients electronic devices and some Aids for Daily Living (ADL) assistance are of the utmost importance.

[The McVay technic for inguinal hernia cure. Results of treatment in a teaching center (author's transl)]

Over a 20 year period 390 adults underwent 454 operations for inguinal hernia using the technique of McVay. The recurrence rate after primary repair was 7.61% and 18.33% for secondary hernias. This was usually early in the postoperative period. These results must be interpreted taking into a ccount that the operations were performed at a teaching institution.

A prosthetic appliance for a patient with a brachial plexus injury and forearm amputation: a case report

Among the prosthetic and orthotic appliances available, neither a conventional mechanical prosthesis nor the myoelectric control system provided optimal results for a 19-year-old patient with a traumatic, irreversible paralysis of the brachial plexus and below-elbow amputation. A new device was therefore constructed that combined the mechanical pull of the first system and the electric hand of the second. Its functions, the training program, and the end result are reported.

Strontium 87m scanning of the sacroiliac joints in ankylosing spondylitis

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