Botulinium toxin type A injections as an effective treatment in rehabilitation of neurogenic bladder in spinal cord lesions

Bladder management after a spinal cord injury [SCI] is a critical consideration from the onset of the condition. Inadequate management resulted in a high incidence of morbidity and mortality in the past. As better awareness has been generated, a dramatic decline in associated pathologies has occurred. The medication commonly called Botox is a purified toxin made from the botulinum bacillus. It has become standard therapy in the management of a variety of muscle spasm disorders and has found new uses in certain Urological conditions, as well. To evaluate the effectiveness of focal injections of botulinum toxin type A [BTX-A] for treating neurogenic detrusor overactivity [NDO] in patients with SCI for relieving symptoms of urinary incontinence [UI] and reducing raised detrusor pressure associated with the risk of renal complications. This randomized, placebo-controlled study investigated the effect of 2 doses of BTX-A versus placebo in patients with post-traumatic SCI, who were suffering from NDO that was inadequately managed on oral anticholinergics and required clean intermittent self catheterization [CISC]. We included 54 patients who were randomized into three treatment groups [A, B, C]. Group A: received a total of 200 IU of BTX-A; included 19 patients [14 males and 5 females], their mean age was 33.4 years [yr] +/- 9.8 SD, ranged from 16 to 53 yrs with disease duration of NDO was 16.2 +/- 7.3 months [ranged from 8 to 36 months]. Group B: received a total of 300 IU of BTX-A, consisted of 20 patients,16 males and 4 females, their mean age was 34.5 yrs +/- 8.7 SD, ranged from 16 to 47 yrs, with disease duration of NDO was 14.5 +/- 9.1 months [ranged from 5 to 33 months]. Group C: [placebo], included 15 patients, 12 males and 3 females, their mean age was 32 yrs +/- 8.0 SD, ranged from 16 to 44 yrs with disease duration of NDO was 16.8 +/- 8.6 months [ranged from 7- 36 months]. Patients were randomized to receive a single intravesical dose of BTX- A 200 U [group A] or 300 U BTX-A [group B] or placebo [group C] administered evenly over the detrusor muscle via 30 intradetrusor injections, each of 1 ml, into the detrusor via cystoscopy, avoiding the trigone and base. For outcome analysis, we used a bladder diary, an urodynamic examination, and a questionnaire of life. Changes in UI frequency, Urodynamic parameters were maximum cystometric capacity [MCC], maximum detrusor pressure [MDP] during bladder contraction, reflex detrusor volume [RDV], and quality of life [using the Incontinence Quality of Life [I-QOL] questionnaire] at baseline and over 24 weeks following injection. Both BTX-A treatment groups showed significant changes at all time points following injection, whereas no such changes were seen with placebo. Changes in bladder diary at week 2,6,12,18 and 24 weeks after BTX-A injection as follows: frequency of UI episode was reduced by 31%, 47%, 47%, 53% and 63%, respectively in group A and by 50%, 60%, 65%, 65% and 73%, respectively, in group B. Favorable significant changes in urodynamic parameters from baseline were also seen for both BTX-A groups, including increased MCC, decreased MDP and increased in RDV. Scores for [I-QOL] were significantly improved for both BTX-A groups from baseline and differed significantly from placebo at all time points; The MCC were significantly increased [p<0.05] from 276.3 +/- 17.4 mL to 465.0 +/- 39.4 mL and from 281.8 +/- 16.8 mL to 463.5 +/- 38.9 mL in both groups A and B at week 2, respectively. MCC had increased by 68%, 61%, and 57%, respectively, at the same intervals at week 2, 8 and 24, respectively in group A patient group and by 64%, 61% and 59% in group B. The MDP had decreased by 41%, 38% and 33% at week 2, 8 and 24, respectively in group A and by 42%, 39% and 33% in group B. The RDV had increased by 22%, 10% and 23% at week 2, 8 and 24, respectively in group A and by 11%, 4% and 10% in group B. BTX-A was well tolerated with virtually no side effects. The overall improvement in QOL was maintained up to 24 weeks. BTX-A was effective in reducing UI episodes and improving urodynamic parameters in patients with UI due to NDO. BOTOX may be an important therapeutic option for improving neurogenic bladder management and reducing the risk of vesicoureteric reflux, potentially preventing upper urinary tract deterioration and kidney damage. BTX-A has excellent safety profiles indicates that this treatment may also be beneficial for patients with UI of non-neurogenic origin

Comparison of sensitivity of lumbrical and interossei latency recording and standard median nerve conduction studies in electrodiagnosis of carpal tunnel syndrome

Carpal tunnel syndrome [CTS] is the most widely known entrapment neuropathy. Electrophysiological procedures e.g., nerve conduction studies [NCSs] are of established value in the diagnosis of CTS and can confirm the clinical diagnosis in the majority of patients. It also detects an incidental finding in some asymptomatic subjects. One must therefore carefully check the test results and the clinical findings before resorting to surgical intervention. However, there are patients with symptoms and signs suggestive of CTS who remain difficult to diagnose with standard electrodiagnostic tests. A variety of NCSs have been employed to demonstrate patients with mild CTS. The lack of sensitivity of distal motor latency [DML] may be due to either to sparing of motor as compared to sensory fibers or to the inability of standard median motor studies to detect an abnormality. To demonstrate early and mild CTS and compare sensitivity of standard median NCSs with 2[nd] lumbrical and interossei latency differences using the same active recording electrode placed over the motor point of 2[nd] lumbrical lateral to the 3[rd] metacarpal with stimulation of median and ulnar nerves at wrist at equal distances. This study included 40 normal control hands and 61 patients hand with CTS; the control group was 14 males and 28 females; their mean age was 39.5 years [yrs] +/- 9.9 SD, ranged from 21 to 56 yrs. The patients group included 61 patient hands with clinical signs and symptoms suggestive of CTS [i.e., paresthesias in the median nerve distribution, nocturnal symptoms, intermittent wrist and arm pain, positive Tinel's and Phalen's signs, etc...].They were subsequently proven to have CTS with electrophysiological median nerve standard NCSs; they were 15 males and 46 females, their mean age was 45 yrs +/- 10.8 SD, and their age ranged from 28 to 63 yrs. All subjects were subjected to electrophysiological standard median NCSs e.g., DML to abductor policis brevis [APB], median nerve Antidromic distal sensory latency [ADSL] to index finger, median and ulnar ADSL differences to ring finger, and compared with 2[nd] lumbrical and interossei latency differences. A prolonged 2[nd] lumbrical - interossei latency differences > 0.4 msec was found to be a sensitive indicator of CTS in all patients; the sensitivity of the 2[nd] lumbrical- interossei latency difference [96%] was higher than the highest sensitive test of standard median NCSs [Median - Ulnar ADSL difference] [89%]. CTS patients were divided into Grade 1. Very mild CTS, Grade 2. Mild CTS, Grade 3. Moderate CTS, Grade 4. Severe CTS and possible CTS; the sensitivity or percentage of abnormal 2[nd] lumbrical-interossei latency differences was 80%, 87%, 95%, 100% and 67%, respectively. Thus, the more sensitive the study needed to demonstrate the CTS, the more severe the CTS was graded. The comparison of 2[nd] lumbrical and interossei latency differences is a sensitive measure technique can help and demonstrate early and mild CTS patients as it is safe, simple and easy to perform in any electrophysiology laboratory. We provide the evidence of 2[nd] lumbrical-interossei latency differences that could be a standard technique for electrodiagnosis of CTS

Hyaluronate as a biomarker for rheumatiod arthritis activity

Hyaluronic Acid [HA] in synovial tissue may leak into the circulation during synovial inflammation. So serum HA levels are expected to be elevated in rheumatic diseases with synovial involvement such as rheumatoid arthritis. To study the clinical specificity of HA for rheumatoid arthritis [RA] as a possible biomarker related to cartilage and bone turnover and its relation to disease activity. Serum samples from 50 RA were tested. 20 serum samples from healthy blood donors were used as controls. HA serum level in ng/ml was determined using an ELISA-based assay, and correlated with the clinical and laboratory variables. RA patients had mean age 45.9 +/- 7.8 SD years and duration of disease was 2.4 +/- 1.2 years. The study showed significant correlations between the serum HA level and the indices of disease activity, joint swollen scores [R=0.77, p<0.05], morning stiffness [R=0.67, p<0.05], erythrocyte sedimentation rate [ESR] [R = 0.78, p<0.05], C-reactive protein [CRP] [R=0.79, p<0.05] in RA patients. There was significant correlation with disease duration [R=0.68, p<0.05] and Ritchie articular index [RAI] [R=0.82, p<0.05]. No significant correlation of HA level with age of RA patients was observed [R=-0.28, p>0.05]. Serum HA level is a useful marker for the activity and severity of disease in RA patients

Detection of anticardiolipin and antinuclear antibodies in juvenile idiopathic arthritis and their relation to disease activity

Juvenile Idiopathic Arthritis [JIA] is an autoimmune disorder. The American College of Rheumatology defined juvenile arthritis as a chronic condition that causes inflammation in one or more joints and begins before the age of sixteen. Juvenile arthritis may be difficult to diagnose because children often compensate well for loss of function and may not complain of pain. Observations of limping, stiffness when awakening, reluctance to use a limb or reduced activity level may be clues. Anticardiolipin antibodies [aCL] have been demonstrated in a large spectrum of autoimmune diseases. However, its occurrence in childhood, in particular in JIA, is not well established. The present study addressed the frequency and clinical significance of aCL and to find an association of aCL and antinuclear antibodies [ANA] with JIA and their correlation to clinical picture, functional capacity and disease activity. Thirty five children were included in this study. The patients group consisted of 20 children [6 boys and 14 girls] with JIA according to the American College of Rheumatology [ACR] 1987 criteria and fulfilling the criteria for diagnosis of JIA [Cassidy and Pretty, 1990]. Their mean age was 12.0 years [yr] +/- 2.6 SD, ranged from 8.3 to 16 yr, with a mean of disease duration 3.4 yr +/- 1.1SD, ranged from 1.4 to 5.0 yr. The control group consisted of 15 healthy children [6 boys and 9 girls] with a mean age of 11.9 [yr] +/- 2.2 SD, their ages ranged from 7.3 to 15.3 yr. The JIA patients group was further classified into two subgroups according to the onset of the disease into systemic onset [no.= 7] and polyarticular-pauciarticular [P-P] [no.= 13]. All groups were subjected to complete history taking and physical assessment of local articular and systemic manifestations. Assessment of the degree of disease activity for JIA patients was performed according to Mallya and Mace scale [1981]. The functional capacity in all subjects was assessed according to Juvenile Arthritis Function Assessment Scale [JAFAS]; this scale ranged from 0 to 20. Blood samples were collected and subjected to the following tests: Complete blood count [CBC], ESR, C- reactive protein, Latex agglutination slide test for RF, and assessment of aCL [IgG and IgM] antibodies and ANA using ELISA method. There was increased incidence of disease in females rather than males [nearly double] and the P-P in patients represented 65%. There was a significant increase of ESR and serum levels of ANAs, aCL [IgG and IgM] autoantibodies and JAFAS [p<0.05] in the JIA patient groups as compared to the control group. There was a significant increase of ESR, AI and activity grade in systemic onset group as compared to P-P patients group [p<0.05]. The correlation study in P-P patients group determined a significant negative correlation between aCL- IgG with patient's age of onset and morning stiffness [p<0.05]. A significant positive correlation was found between disease duration with age [p=0.03] and no. of swollen joints [p=0.009]. In the systemic onset patients group, there was a non-significant correlation of aCL-IgG with any clinical or laboratory data [p>0.05], while significant negative correlations was found between aCL-IgM with age, age of onset, JAFAS and ANAs [p<0.05]. There was a positive significant correlation between ANAs and no. of swollen joint [r=0.79, p=0.04] and JAFAS [r=0.78, p=0.04]. We encountered two JIA female patients having positive aCL and ANA antibodies who manifested as P-P onset of the disease. They should have clinical follow up and regular ophthalmologic examination as they are highly susceptible for uveitis. The presence of aCL was not associated with ANA. The relation of aCL with the clinical parameters, could not be established. Age of disease onset, sex, disease activity, and JAFAS could be a prognostic indicator rather than immunological profile tests

Factors affecting rehabilitation of elective hip and knee arthroplasty and length of hospital stay

Total hip arthroplasty [THA] and total knee arthroplasty [TKA] are among the most common operative procedures[1]. Over the past 35 years, the use of these procedures has grown dramatically, providing pain relief and improving the quality of life for millions of patients. During this time, the role of rehabilitation has been emphasized as an integral part of the post-operative management of the patient. Instead of spending days in bed waiting for tissue to heal, patients now begin functional activities as early as the first postoperative day [1][2]. The purpose of this study was to predict the factors that affect the length of hospital stay. We also planned to sort out which patients admitted for total joint arthroplasty [TJA] will be discharged to home and which patients will require transfer to a rehabilitation ward at the time the surgery is planned. Sixty-four patients with mean age of 64.9 years [39 women and 25 men] have had 71 operations of elective TJA [43 TKA, 7 bilateral TKA, and 21 THA] by 4 surgeons were studied. All the patients had started early intensive rehabilitation program on the first postoperative day to attain good outcome until discharged to home functionally independent. The correlation of patient's age, sex, marital statues, body mass index, and pre-morbid illness with length of hospital stay in either orthopedic or rehabilitation ward and the need for admission to rehabilitation was studied. It was found that age was the only characteristic factor that significantly correlated to the length of stay in either the orthopedic and rehabilitation ward. The co-morbid illnesses that affect the length of hospital stay and need for inpatient rehabilitation were diabetes mellitus and obesity

Sympathetic skin response in evaluation of autonomic nervous system functions in post-stroke patients

Strokes are the most common serious neurological disorder. They are third leading cause of death after heart disease and cancer. A wide spectrum of dysautonomic symptoms affecting different systems can occur in cerebrovascular accident patients including the cardiovascular, gastrointestinal, genitourinary, papillary, sudomotor and neuroendocrine systems. In this study, we aimed to investigate the sympathetic and parasympathetic autonomic nervous system dysfunctions in hemiplegic or hemiparetic patients after a cerebrovascular accident [CVA]. Sympathetic skin response [SSR] was done in a total 33 individuals: twenty-one hemiplegic or hemiparetic patients after cerbrovascular accidents. The control group consisted of 12 apparently healthy persons. The SSR was recorded bilaterally with median nerve stimulation in both affected and non-affected sides. The mean age of the patients' group was 61.5 yr [34-77yr], nine of them were acute acute [<30 days] and 12 in the chronic stroke phase [>1month]. The control group had a mean age of 53.2 years [range 33-67 yr]. The disease duration in the stroke patients was 5.9 months [1-14 months]. There was a significant [p<0.05] low amplitude and prolonged latency of the SSR recorded in the affected side of stroke patients as compared to normals. On the other hand, there was no significant difference of both amplitudes or latencies of SSR recorded on the affected and unaffected sides. Patients with brainstem lesion showed significant [p<0.05] low amplitude and delayed latency as compared to normal, while there was no significant difference with patients having cortical and subcortical lesions. SSR is a simple, quick and non-invasive electrophysiological test to evaluate the dysfunction in the autonomic nervous system in post stroke patients. The autonomic nervous system [ANS] in post stroke patients is partially inhibited and this may be useful to predict any possible complications during the rehabilitation program